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ABSTRACT Objective To evaluate the impact of assistance from public and private health systems on the overall survival of patients with metastatic prostate cancer. Methods A total of 213 patients with metastatic prostate cancer treated at the A.C. Camargo Cancer Center, either in the Unified Health System or a private system, from January 2014 to December 2018 were analyzed. Multivariate analysis of overall survival was performed to adjust for the type of health assistance and other clinical prognostic factors. Results Of 213 included patients, 147 (69%) were from the private system and 66 (31%) were from the Unified Health System. There was a significant difference in the median age at diagnosis between the systems (63.4 years for patients in the private system versus 67.2 years for patients in the Unified Health System, p=0.027). No significant differences in performance status were observed between the groups (p=0.695). Patients treated in the public system had access to fewer treatment lines (2.59 lines in the public system versus 3.04 lines in the private system, p=0.024). Our data revealed a longer median survival for patients with private health care (115 months for patients with private health care versus 78 months for patients in the Unified Health System, p=0.009). Multivariate analysis revealed that patients in the public system had a 66% higher risk of death than those in the private system. Conclusion Our data demonstrate that patients in the Unified Health System have access to fewer lines of therapy for metastatic prostate cancer, resulting in shorter median survival than patients treated in the private system.

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ABSTRACT Objective To compare the epidemiological profiles of patients who experienced extubation failure with those who achieved success and to evaluate the impact of extubation failure on total mechanical ventilation duration. Methods An observational study with both retrospective and prospective components was conducted on patients admitted to the Pediatric Intensive Care Unit of a private hospital. This study included patients who underwent mechanical ventilation and were extubated between January 2017 and December 2022. Patients were classified into extubation Success or Failure Groups, with failure defined as requiring a return to invasive mechanical ventilation within 48hs post-extubation. Epidemiological factors, including age, pre-existing illnesses, and time on invasive mechanical ventilation, were analyzed. Results A total of 173 patients were included, of which 9 (5.2%) required reintubation within 48hs. The total duration of mechanical ventilation differed significantly between the Success Group (3 days [1.8; 6.6]) and the Failure Group (6.5 days [5.6; 9.3]), p=0.004. Upper airway obstruction was identified as the primary cause of extubation failure. Conclusion This study demonstrated that extubation failure doubled the total duration of mechanical ventilation compared to successful extubation. These findings highlight the importance of daily patient assessment with clearly defined clinical criteria to ensure mechanical ventilation is discontinued precisely when the patient is ready-neither prematurely nor excessively delayed.

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ABSTRACT Objective Chemotherapy-induced nausea and vomiting are highly prevalent adverse events that can lead to poor treatment adherence and a decreased quality of life. To the best of our knowledge, the complete omission of dexamethasone from any regimen for preventing nausea and vomiting has not yet been evaluated. This study aimed to evaluate the efficacy of a three-drug protocol without corticosteroids for preventing nausea and vomiting. Methods This prospective, single-arm, phase II study was designed to evaluate the efficacy of olanzapine, netupitant, and palonosetron in controlling nausea and vomiting induced by emetogenic chemotherapy. Patients were assigned to receive olanzapine on days 1-5 and netupitant and palonosetron on day 1. No corticosteroids were administered. The primary endpoint was complete nausea control during the first 5 days after chemotherapy. Secondary endpoints included complete emesis control (no emesis and no use of rescue medication) and overall complete control (no emesis, no rescue medication, and no nausea). Results The complete nausea control rate was 46% (95% confidence interval [95%CI] 0.32-0.59). The emesis control rate was 68% (95%CI= 0.55-0.80), and the overall control rate was 46% (95%CI= 0.32-0.59). Conclusion These findings suggest that omitting dexamethasone in highly emetogenic chemotherapy is feasible and results in nausea and vomiting control rates similar to those of the standard four-drug protocol. However, randomized controlled trials are required to confirm this hypothesis.

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ABSTRACT Objective This study aimed to evaluate the clinical manifestations of SARS-CoV-2 in children and adolescents with cystic fibrosis. Methods This was a case-control analysis of clinical variables and pulmonary function test results in 43 children with cystic fibrosis, 17 (39.5%) of whom tested positive for SARS-CoV-2. Results The infected children exhibited a higher frequency of dyspnea and cough and a greater need for hospitalization. One infected child died. Pulmonary exacerbations were more frequent among the infected children. Additional data indicated a subsequent reduction in pulmonary function in the infected children, although this was not significantly different from that in the uninfected children. Conclusion Children with cystic fibrosis who contracted SARS-CoV-2 experienced mild to moderate symptoms and required hospitalization but generally had high recovery rates.

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ABSTRACT Objective To evaluate the quality indicators proposed by the American Academy of Neurology and Neuro-oncology Society in patients with primary intracranial central nervous system tumors. Methods This study is a retrospective level I analysis that used electronic medical records from the CERNER system and GDOC-SAME at the tertiary hospital. It was approved by the Research Ethics Committee and followed the Declaration of Helsinki. Data was collected and analyzed confidentially via REDCap. The research focused on patients 18 or older with primary central nervous system tumors who had surgery from August 2015 to August 2021. It excluded surgeries performed elsewhere, reoperations, secondary (metastatic) tumors, and primary central nervous system tumors outside the cranium. Results The results showed that 48% of the patients had gliomas, whereas 30 and 21.6% had meningiomas and other types of tumors. Quality measures showed that 35% of the patients with grade 2-4 tumors had multidisciplinary care plan discussions. All patients with gliomas underwent molecular testing and those eligible who underwent chemotherapy were educated and provided informed consent. Postoperative magnetic resonance imaging within 72h was performed in 87% of gliomas. The length of hospital stay, postoperative complications, Eastern Cooperative Oncology Group status at discharge, and 30-day status were also potential quality measures. However, for meningioma cases, readmissions were associated with patients in the American Society of Anesthesiologists II (58.33%) and American Society of Anesthesiologists III-IV (41.67%). Conclusion The study conclusions revealed that adherence to quality indicators was good; however, improvements are needed in multidisciplinary care plans and postoperative imaging. Quality measures can be enhanced by controlling factors such as American Society of Anesthesiologists and Eastern Cooperative Oncology Group scales at admission, epileptic seizure occurrence, neurological deficits, and tumor size in meningiomas. The study’s findings highlighted the importance of quality improvement programs for optimal medical care.

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ABSTRACT Objective To evaluate the effectiveness of Multiple Mini Interviews as a selection method for medical school admissions at the Faculdade Israelita de Ciências da Saúde Albert Einstein by evaluating the relationship between the Big Five personality traits and the performance of candidates in the Multiple Mini Interviews. Methods All candidates who had completed the NEO PI-R personality test and the socio-demographic questionnaire were the participants of the study. The personality profiles of candidates who participated in the Multiple Mini Interviews process of this cross-sectional descriptive study were analyzed by crossing data to identify significant correlations. Results Of the 225 candidates, 63% were female and the mean age of the sample was 21 years. Only the domain of Conscientiousness showed significant correlations with higher Multiple Mini Interviews scores (p=0.004). Specifically, traits of Conscientiousness such as Competence (p=0.046), Dutifulness (p=0.043), Achievement-Oriented (p=0.050) and Self-Discipline (p=0.028) were associated with better Multiple Mini Interviews performance. Other domains, like Neuroticism, Extraversion, Openness, and Agreeableness, showed no significant correlation. Additionally, socio-demographic factors had no significant impact on performance. Conclusion The findings validate the Multiple Mini Interviews as an effective method for medical school selection, as they correlate with high-value personality traits such as Conscientiousness, while not favoring irrelevant individualities. These results orient the enhancement of selection methods, ensuring a diverse and competent student body and, overall, improving medical education. The findings thus support the use of structured interviews in admission processes, highlighting their role in identifying candidates with essential qualities for success in medical education and practice, and offer valuable insights for similar educational institutions aiming to refine their selection methods.

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ABSTRACT Objective Ambulance transport time is an important metric in prehospital care. Limited studies have explored strategies to decrease on-scene time. We examined the effect of collecting telemedicine-based medical data during ambulance dispatch on the on-scene evaluation time of the prehospital team. Methods This randomized, single-center, open-label study included individuals aged >18 years who independently sought hospital emergency services and requested on-site emergency care. Individuals with primary trauma emergencies occurring outside the home, cardiac arrest cases, and situations in which video communication was unfeasible were excluded. Results Twenty patients were randomized to receive telemedicine assessment during ambulance dispatch or standard care with physician phone support. Both groups were comparable in age (53.2 ± 26.1 versus 63.4 ± 24.2 years, p=0.380), sex (50% versus 70% female, p=0.360), initial vital signs, and medical history. The main reasons for patients calls were falls from standing height (30%), followed by cardiovascular symptoms (20%), and acute neurological events (15%). Teleconsultation via a mobile application was successfully conducted in all cases. Furthermore, in situ interventions, including venous access, oxygen therapy, orthopedic immobilization, hypotension stabilization, and symptomatic treatment, were similar between the groups. The Telemedicine Group demonstrated a significantly shorter on-scene evaluation time (20.45 ± 6 min) than the Standard Group (36.80 ± 20.4 min, p = 0.019). Conclusion Conducting checklist-based anamnesis teleconsultation during ambulance dispatch considerably decreased the on-scene evaluation time of the emergency team. Further research with larger cohorts and different settings is required to better examine telemedicine’s potential in this context.

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ABSTRACT Objective This study aimed to determine the prevalence of human papillomavirus (HPV) 16 infection in the tonsils of patients without cancer and to analyze the associated risk factors in a low-risk population in Brazil. Methods The study included 113 adult patients who underwent surgery for non-neoplastic conditions. The participants completed an interview-based questionnaire on lifestyle habits, including the use of tobacco and alcohol, and a questionnaire on sexual behavior. Overall, 226 freshly frozen tonsil samples were subjected to DNA extraction, conventional polymerase chain reaction using the PGMY09/11 primer for β-globin, and quantitative polymerase chain reaction for HPV16 detection. Results In this cohort, 47 patients (41.6%) were women between 18 and 58 years of age (mean age, 28.5 years), and 66 (58.4%) were men between 18 and 68 years of age (mean age, 34 years). A total of 81 (71.7%) and 46 (40.7%) patients answered questionnaires on lifestyle habits and sexual behavior, respectively. All samples successfully amplified the β-globin gene fragment but tested negative for HPV DNA. This outcome precluded an investigation of the association between risk factors such as sexual behavior and HPV infection. External validation using oropharyngeal squamous cell carcinoma specimens confirmed the reliability of the laboratory procedures to detect HPV DNA, showing a 10% prevalence of HPV infection in the comparator population. Conclusion The findings of this study suggest that the actual prevalence of HPV16 tonsillar infection in the general population without cancer may be lower than that previously reported in Brazil.

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ABSTRACT Objective This study aimed to analyze the influence of Mozart’s Sonata K.448 on contextual memory extinction in male mice. Methods Male mice were divided into three groups (G1-Mozart, G2-Ambience, G3-Control). Throughout the project, only the first group was exposed to the sonata at the intrauterine stage. Only Groups 1 and 2 underwent aversive training; subsequently, all groups participated in extinction and recall tests. Results On the first day of extinction, G1’s freezing time was longer than G2’s and G3’s, whilst on the second day it was only longer than G3’s. Finally, on the fifth day, G1’s freezing time was shorter than that of G2. During the second and third days of extinction, G1’s freezing time decreased more than G3’s, whereas during the fourth and fifth day, G1 upheld its freezing time, whereas G2’s extended. During recall, G1 had a longer freezing time than G3. All results were statistically significant (p≤0.05). Conclusion Based on the results, we concluded that male mice exposed to Mozart’s Sonata K.448 showed increased freezing time, suggesting an impact of the music on memory formation. However, they exhibited a linear extinction memory process. This progressive decrease in freezing behavior was not observed in the ambient and Control Groups.

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ABSTRACT Objective To estimate the incremental cost and survival of patients on the liver transplantation waiting list who were referred for transplantation. Methods We analyzed a cohort of 883 patients who underwent liver transplantation within the Support Program for the Institutional Development of the Unified Health System in Brazil between 2010 and 2022. Median survival was assessed using the Kaplan-Meier method and parametric extrapolation of the survival curve. A bottom-up micro-costing approach was used to direct medical hospital costs. We conducted an economic evaluation comparing patients who received transplant with those who were listed to assess the potential of propensity score matching in reducing bias in this context. Results The economic evaluation revealed a median survival of 15.54 and 1.07 years and a mean cost of US$ purchasing power parity of 162,821.96 and 39,044.79 for patients who received transplant and listed patients, respectively. A reduction in survival and an increase in mean costs for the listed patients were observed following propensity score matching. Conclusion A direct comparison of survival and costs between the two patient groups may lead to biased estimates of the incremental survival or costs associated with referring a patient for a liver transplantation procedure. Propensity score matching reduces the bias from differences in health status between these two patient groups, enabling more accurate estimates of the incremental survival and cost associated with referring a patient for transplantation.

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ABSTRACT The Scientists of Tomorrow project is a partnership between the Postgraduate Program and multidisciplinary teams of the Hospital Israelita Albert Einstein and Escola Municipal de Ensino Fundamental Professor Paulo Freire of Paraisópolis in São Paulo, Brazil. To inspire 9th-grade students, the project introduced scientific research topics and methodologies to answer questions. This four-month program covered cellular and molecular biology, nanotechnology, bioinformatics, big data, neuroscience, and the impact of nature on well-being and innovation. In the second edition, the program featured 17 students and 35 activities from the beginning of August to the end of November 2023. The program connected with clinical practice, offering students insights into pre-clinical and clinical studies, basic life support training, an overview of the Brazilian Public Health System, and anxiety management techniques such as meditation. Diverse teaching strategies enhanced learning, as evidenced by theory-practical classes, pre- and post-tests (p<0.05), Kahoot! quizzes, design thinking, and real-time feedback. Students were encouraged to express their ideas verbally and in writing, individually and in groups. On the final day, the students presented their work in poster sessions, where they answered questions, reflected on their research, interacted with other researchers, and developed communication skills. As an innovative and replicable initiative, Scientists of Tomorrow empowers students to apply knowledge effectively, integrating scientific and technological skills with core values. Aligned with the United Nations Sustainable Development Goals (SDGs), especially SDGs 4 (quality education) and 10 (reducing inequalities), this project promoted continuous learning and self-improvement, preparing students to navigate real-life challenges with flexibility, resilience, and creativity.

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ABSTRACT Objective To develop a process (pipeline) for extracting, processing, and analyzing data from the National Registry of Health Establishments in the State of São Paulo, Brazil, to evaluate the distributions of health professionals and services throughout this state. Methods Big Data resources were used to acquire, process, and aggregate health-related information, with the creation of a relational database for the local storage of processed data. The entire process is implemented using a framework that enables the creation and editing of a series of instructions for performing specific tasks (scripts) in different languages. For the end user interface, an interactive panel of information, metrics, graphs, and numerical indicators was created to show the distribution of health professionals and services across the municipalities of the State of São Paulo. Results The developed tool generates a process for monthly updating of a database, producing a dynamic information report that allows users to perform queries on quantitative and qualitative indicators, providing a general overview of health establishments, and furnishing information on specific health professionals. Conclusion The preliminary results indicated that the developed tool is potentially scalable and could contribute to the identification of regions of the state requiring action from public authorities, helping to optimize the hiring of doctors and community health agents, among others.

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ABSTRACT Objective This study aimed to translate and cross-culturally adapt the Oncology Nurse Navigator Core Competencies 2017 instrument into Brazilian Portuguese. Methods This study used a methodological cross-cultural adaptation approach. After authorization from the authors of the original version of the Oncology Nurse Navigator Core Competencies 2017 comprising 52 competencies, the instrument was translated following the recommended guidelines. A panel of five oncology specialists evaluated and consolidated the translation. To analyze the adequacy of the translation, 59 nurse judges—all oncology nurse navigators—were recruited using the snowball technique. Data was collected between December 2020 and August 2022. Results The first and second rounds of assessing the suitability of the translated competencies involved 24 and 17 judges, respectively. Their average age was 37.5 years and the majority (87.5%) were women. After incorporating the requested adjustments based on feedback from the second round, the questions exhibited satisfactory proportions of agreement and content validity ratios. Conclusion The 52 competencies in 5 categories were adapted and adequate according to the proportions of agreement and content validity ratios, which assumed values compatible with those suggested for adequacy. We therefore conclude that these competencies enable a better understanding of the role and performance of oncology nurse navigators in the Brazilian context.

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ABSTRACT Objective This study aimed to evaluate the effects of different concentrations of vegetable peptones (pea, wheat, and soy) as substitutes for fetal bovine serum in stem cell cultures derived from human exfoliated deciduous teeth. Methods Stem cell cultures derived from human exfoliated deciduous teeth were cultured with peptones in different concentrations [0.5%, 1%, and 5% (w/v)] and 10% fetal bovine serum (v/v) as control, and their proliferation was evaluated through the 3-(4,5-dimethylthiazol2-yl)-2,5-diphenyltetrazolium bromide assay. Osteogenic differentiation was assessed using Alizarin Red to quantify calcium deposition. Results Wheat, soy, and pea concentrations greater than 1% were cytotoxic to stem cell cultures derived from human exfoliated deciduous teeth. In addition, a long-term study showed that pea peptones were cytotoxic. Studies with soy and wheat peptones were continued at concentrations of 0.5% (w/v), and proliferation on day 3 was greater than 50% compared with the control. Wheat peptone presented more mineralized areas than fetal bovine serum. The aminograms of the three peptones showed that the greater efficiency of wheat peptone may be related to its higher proline and glutamic acid proportions. Conclusion We suggest that vegetable peptones at concentrations ≤1%, particularly 1% wheat, can be used as fetal bovine serum substitutes for stem cell cultures derived from human exfoliated deciduous teeth cultivation.

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ABSTRACT Objective: To analyze the immediate analgesic effects of Aussie Current on chronic low back pain using different parameters. Methods: A total of 105 patients (aged 18-80 years, of both sexes, with chronic low back pain) were randomized into five groups: AG1kHz/100Hz, AG1kHz/2Hz, AG4kHz/100Hz, AG4kHz/2Hz, and placebo. All participants underwent a single application of the Aussie Current for 30 min. The assessments were conducted before and immediately after the intervention, with the following outcomes: pain intensity using the numerical pain rating scale, McGill Pain Questionnaire, mechanical pain threshold, and five-times-sit-to-stand test before and immediately after the intervention. The Start-Back Questionnaire was administered before the intervention to analyze the physical and psychosocial factors related to chronic lower back pain. Results: In the intragroup analysis, all groups showed significant differences in the numerical pain rating scale and total McGill Pain Questionnaire index. For the mechanical pain threshold, a significant difference was observed in the AG1kHz/100Hz Group at three points in the lumbar region and in the five-times-sit-to-stand test at AG1kHz/100Hz, AG1kHz/2Hz, and AG4kHz/100Hz. In the intergroup comparison, there was a significant difference in the numerical pain rating scale scores between the AG1kHz/100Hz and AG1kHz/2Hz Groups in the Placebo Group. Conclusion: Aussie Current provides an immediate analgesic effect in individuals with chronic low back pain; however, there is no consensus on the ideal parameters. ClinicalTrials.gov Identifier: RBR-98HJ9X.

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ABSTRACT Objective: This study compared the productivity of prison oral health teams during the COVID-19 crisis (2020–2022) with the previous three-year period (2017–2019) to identify the number and type of dental procedures performed. Methods: We employed an ecological and retrospective study using Primary Care Health Information System data. We analyzed data from all municipalities that reported the productivity of Prison Primary Care Teams from 2017 to 2022, totaling 418 municipalities distributed across all five Brazilian regions. Data pertaining to 15 oral health procedures were collected and subsequently grouped into five categories: preventive, urgent, extraction, periodontics, and restorative. The data revealed a non-normal distribution and were evaluated using the Wilcoxon test. Results: The findings revealed inequality between regions, with the productivity of several municipalities being close to or equal to zero. Although the number of restorative procedures reduced in both periods (2017-2019 and 2020-2022), it was not statistically significant. However, statistically significant increases were observed, with the exception of restorative and periodontal procedures. Urgent and extraction procedures prevailed over restorative and periodontal treatments. Conclusion: Access to Brazilian oral health procedures for inmates is low and remained unaffected by the pandemic, maintaining similar characteristics with increased productivity during that period.

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ABSTRACT Background: The use of long-term devices for chemotherapy in neoplastic diseases is very common. The CAVA trial was an extensive study that prospectively evaluated more than 1000 patients undergoing chemotherapy and randomly allocated them to three groups based on the type of catheters used: peripherally inserted central catheters, Port, or Hickmann. For this study, the Quality of Life Vascular Access Device (QoLVAD) questionnaire was administered to assess the impact of these devices (abovementioned catheters) on the patients’ daily lives. routine However, no Brazilian Portuguese version of the questionnaire exists, hindering its use among Brazilian patients. Objective: To translate the CAVA trial QoLVAD to Brazilian Portuguese and validate it so that it can be used in the Brazilian population. Methods: A total of 167 patients with long term vascular access devices for chemotherapy participated in the study. After translation and retranslation, construct validity was analyzed by identifying the correlation between QoLVAD and the European Quality of Life Questionnaire (EuroQol). To determine the reliability, internal consistency and test-retest analysis with at least a 7-day interval between two administrations of the questionnaire were calculated. Results: The results revealed good internal and external consistency of the QoLVAD. Significant correlations were found between the QoLVAD and EuroQol (r −0,658 and p<0.001). Conclusion: The Brazilian Portuguese version of the QoLVAD exhibited good clinimetric properties and proved to be applicable to the Brazilian population.

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ABSTRACT Objective To analyze the impact of a serious immersive virtual reality game on the physiological and behavioral aspects of pain during peripheral venous access or central catheter puncture in children and adolescents with cancer. Methods This was a longitudinal intervention study that included 50 children and adolescents undergoing cancer therapy and peripheral venipuncture or venous catheter puncture (totally implanted or central venous catheter) at two independent time points (control and experimental intervention). The intervention consisted of playing a serious immersive virtual reality game with three-dimensional goggles and a Bluetooth controller. The patients were monitored for alterations in physiological (heart rate and oxygen saturation) and behavioral (agitation, crying, and pain assessed using the Faces Pain Scale-Revised and Visual Analogue Scale) parameters. An agreement analysis was conducted by calculating the weighted kappa coefficient; p was obtained using Bowker’s symmetry test. Results Use of immersive virtual reality significantly reduced heart rate, improved pain control as assessed by the Faces Pain Scale-Revised, and decreased agitation and crying. Conclusion Serious immersive virtual reality games reduce pain and distress during repetitive and uncomfortable procedures such as venipuncture and venous catheter puncture in children and adolescents with cancer. This strategy is simple to implement, cost-effective, and should be considered by health care services assisting pediatric patients with cancer.

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ABSTRACT Objective To identify complications following transrectal posterior biopsies in a public Brazilian reference center, and to identify the risk factors associated with complications. Methods This is a prospective cohort study that employed a form designed by the Global Prevalence Infections in Urology study. Data from 1,043 consecutive patients who underwent transrectal prostate biopsy at a single Brazilian center were analyzed, including patient characteristics, procedural characteristics, and self-assessed complications at 28 days. Complications were categorized according to the Clavien-Dindo (CD) classification. Results Most bleeding complications were mild (CD Grade 1), although 1.5% reported Grades 2–3. Hypertension, younger age, and anticoagulant use were associated with bleeding (all p<0.001). A total of 4.7% reported infections (CD Grade 2: 0.5%, CD Grade 3: 3.6%, and CD Grade 4 [sepsis]: 0.6%), with risk factors being indwelling catheter use, recent urinary tract infection (p<0.001 for both), and quinolone use (OR= 3.01, 95%CI= 1.15–7.80, p=0.03). Urinary retention was observed in 4.1% (Grade 2), with severe symptoms (p=0.009), prostates >89mL (p=0.001), and prostatic protrusion ≥10mm (p=0.001) being associated with it. Conclusion Clinically significant (CD Grades 3–5) adverse effects of transrectal prostate biopsy are rare. Careful pre-procedure evaluation of antimicrobial use, particularly quinolones, along with the assessment of identified risk factors is essential for counseling patients and reducing potential risks.

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ABSTRACT Objective To evaluate the roles of miR-137 and its target genes in lipid metabolism and prostate tumorigenesis. Methods We used a series of bioinformatic approaches to establish the relationship between miR-137 and its target genes. We mapped the metabolic pathways of interest in the Reactome database and identified the central target genes of miR-137 in this pathway using four platforms: Reactome, miRDB, miRmap, and TargetScan. To assess the expression and association with clinical parameters, we obtained information from the UALCAN, OncoDB, and GEPIA2 databases using a dataset of patients with prostate cancer from The Cancer Genome Atlas. For functional enrichment analysis and construction of the protein-protein interaction network, we used the Kyoto Encyclopedia of Genes and Genomes, Gene Ontology, and STRING. Results Our in silico study of The Cancer Genome Atlas database revealed that miR-137 is underexpressed in tumor tissues, and its reduction is associated with poor prognosis. An intriguing set of eight genes within the PPARα pathway: PPARGC1A, PPARGC1B, NCOA1, NCOA2, NCOA3, MED1, MED27, and ESRRA displayed synergy, positive correlations, and synchronized expression patterns in adipose, hepatic, and prostatic tissues, all linked to the enigmatic processes of metabolic regulation. Among the highlighted genes, ESRRA was overexpressed in the malignant environment, whereas its counterparts remained underexpressed. The plot was thickened with associations between the expression of NCOA1, NCOA3, and MED27, lymph node involvement, and the overexpression of several genes linked to advanced prostate cancer stages. An intriguing pattern emerged, with patients exhibiting reduced disease-free survival overexpressing NCOA2, NCOA3, MED27, and ESRRA. Conclusion This study elucidates the possibility that miR-137 subtly modulates metabolic genes in prostate cancer, suggesting its latent therapeutic potential as a biomarker for disease progression.

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ABSTRACT Objective To evaluate whether the total tumor diameter (sum of the largest diameters of all foci) predicts tumor aggressiveness at initial presentation and treatment response at 1-year follow-up in patients with multifocal papillary thyroid microcarcinoma. Methods A retrospective analysis was conducted on 475 patients with differentiated thyroid carcinoma. Fifty-two patients with multifocal papillary thyroid microcarcinoma were included. The primary variable was total tumor diameter, and outcomes included initial tumor aggressiveness, evaluated according to the American Joint Committee on Cancer (AJCC; stages I or II), risk of recurrence according to the American Thyroid Association (low or not low), and response to therapy at 1 year (excellent or not). Results AJCC stage II disease was significantly associated with age ≥55 years, lymph node dissection, angiolymphatic invasion, extrathyroidal extension, lymph node metastasis, number of metastatic lymph nodes, non-low risk of recurrence, first stimulated thyroglobulin, and response to therapy at 1-year. Non-low risk of recurrence were associated with Bethesda V/VI cytology, lymph node dissection, angiolymphatic and tumor capsule invasion, extrathyroidal extension, lymph node metastasis, number of metastatic lymph nodes, first stimulated thyroglobulin, and radioiodine dose. Non-excellent response at 1-year follow-up were associated with preoperative thyroid-stimulating hormone levels, lymph node metastasis, number of metastatic lymph nodes, and first stimulated thyroglobulin. Multivariate analysis revealed that only the number of metastatic lymph nodes independently predicted AJCC stage. Conclusion Total tumor diameter was not associated with initial tumor aggressiveness or treatment response at 1-year follow-up in patients with multifocal papillary thyroid microcarcinoma.

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ABSTRACT Objective: Post-COVID symptoms are frequent and can be debilitating, particularly in individuals with cancer. However, their impact on this population remains unclear. This study aimed to prospectively assess the symptoms and impairments following COVID-19 hospitalization in patients with cancer, focusing on fatigue, nutritional status, speech and swallowing, anxiety, depression, and posttraumatic stress disorder symptoms. Methods: This prospective observational cohort study included cancer survivors hospitalized with COVID-19 between June and December 2020. We assessed symptoms and impairments related to fatigue, independence in activities of daily living, speech and swallowing, voice, nutritional risk, anxiety/depression, and posttraumatic stress disorder. The participants were assessed at discharge and after 1, 3, 6 and 12 months. Results: A total of 51 participants were included in the study. At the time of discharge, 98% had at least one of the following impairments: fatigue (68.6%), anxiety/depressive symptoms (17.7%), voice and speech impairments (19.6%), dysphagia (21.6%), or nutritional risk (45.1%). By one year, impairments persisted in 66% of the sample: fatigue (34.2%), anxiety/depressive symptoms (19.5%), voice and speech impairments (12.2%), and dysphagia (17.1%), with no participants remaining at nutritional risk. The participants reported no significant limitations in their daily living activities. Conclusion: Cancer survivors hospitalized for COVID-19 presented with high levels of fatigue, nutritional risk, anxiety/depression, and posttraumatic stress disorder symptoms at discharge, with improvements in fatigue and nutrition after one year.

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ABSTRACT Objective: To analyze the association between calf circumference and cardiovascular indicators in men and women with symptomatic peripheral artery disease. Methods: This cross-sectional study included 259 patients with peripheral artery disease (65% men; mean age, 67 [±12] years; ankle brachial index, 0.58 [0.26]). We measured calf circumference, brachial and central blood pressure, arterial stiffness indicators (carotid-femoral pulse wave velocity and augmentation index), and heart rate variability parameters. Multiple linear regression was used to evaluate the association between calf circumference and cardiovascular indicators after adjusting for age, ankle-brachial index, and walking capacity. Results: In women, calf circumference was inversely associated with central blood pressure (systolic: β=-1.91 [0.70] mmHg, p=0.008; diastolic: β=-0.97 [0.29] mmHg, p=0.001), augmentation index (β=-1.06 [0.28]%, p<0.001), and augmentation index corrected by 75 bpm (β=-0.90 [0.23]%, p<0.001), independent of age, ankle brachial index, and walking capacity. After further adjustments for anti-hypertensive medication use and body mass index, carotid-femoral pulse wave velocity was the only parameter associated with calf circumference (β=-0.41 [0.15] m/s, p=0.010). In men, no significant association was observed between calf circumference and cardiovascular indicators (p>0.05). Conclusion: In women with peripheral artery disease, calf circumference was inversely associated with arterial stiffness. This finding suggests that a lower calf circumference may serve as an indicator of increased arterial stiffness in women with peripheral artery disease.

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ABSTRACT Objective: To analyze changes in surgical volume across different specialties in Brazil before, during, and after the COVID-19 pandemic. Methods: This descriptive observational study compared surgical volumes for the specialties with the highest number of procedures each year from 2019 to 2023. Data were sourced from the Department of Informatics of the Unified Health System (DATASUS - TabNet). Results: A total of 2,117,383 surgical procedures across 13 operation types were analyzed. Between 2019 and 2020, surgical volume declined by 35%, with reductions ranging from -1% to -54% depending on the procedure. Although volumes increased by 2023, this was insufficient to address the backlog of delayed surgeries. Otorhinolaryngology and urology were the most affected specialties, while cholecystectomy saw a net post-pandemic increase. Conclusion: The COVID-19 pandemic significantly disrupted all analyzed surgical procedures in Brazilian Public Health System, resulting in a 35% overall decline. Despite partial recovery, the persistent surgical deficit remains a major challenge, reflecting patterns observed internationally.

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ABSTRACT Objective: To analyze the overall and disease-free survival of patients with oropharyngeal squamous cell carcinoma. Methods: Sociodemographic and clinical data, HPV status, and alcohol/tobacco consumption were assessed among patients treated at AC Camargo Cancer Center, São Paulo, Brazil. Absolute and relative frequencies, overall survival, and disease-free survival at 5 and 7 years were calculated using Kaplan-Meier analysis, and Cox regression was used to estimate the risk of death. Results: The 7-year overall survival rate was 61.6% for patients with oropharyngeal squamous cell carcinoma (67.5% for HPV-positive cases and 51.1% for HPV-negative cases). Among HPV-positive cases, the risk of death was 5.29-fold higher for smokers than that for non-smokers (p<0.001) and 4.42-fold higher for patients with metastasis than that for those without (p=0.108). Among HPV-cases, those with clinical stage T3/T4 disease had a 1.8-fold higher risk of death than those with T1/T2 disease (p=0.039), and those with metastasis exhibited a 4.62-fold higher risk than those without (p<0.001). The 7-year disease-free survival rate for oropharyngeal squamous cell carcinoma was 88.6% (90.1% for HPV-positive cases and 85.9% for HPV-negative cases). Among HPV-positive cases, patients with metastasis had an 11.75-fold higher risk of recurrence than those without (p<0.001); among HPV-negative cases, patients with metastasis had a 4.62-fold higher risk than those without (p=0.004). Conclusion: Patients with HPV-positive oropharyngeal squamous cell carcinoma had higher overall survival and increased recurrence rates within the first 3 years but lower recurrence rates beyond 5 years than patients with HPV-negative disease. More frequent follow-ups after 5 years are recommended for patients with HPV-positive disease. Tobacco and alcohol consumption negatively affect the overall survival of patients with HPV-positive oropharyngeal squamous cell carcinoma.

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ABSTRACT Objective: Convulsive status epilepticus is the most common neurological emergency in children with high morbidity and mortality rates. Intranasal midazolam administration using an atomizer is the preferred treatment method. However, Brazilian pediatric emergencies often require rapid midazolam instillation using syringes. We aimed to compare the plasma midazolam levels in children who received intranasal medication with an atomizer and those who received medication via rapid instillation using only a syringe to treat seizures. Methods: This exploratory cross-sectional study was conducted between January 2022 and March 2024 at the emergency department of a hospital in Southern Brazil. Thirteen children with tonic-clonic status epilepticus received intranasal midazolam via either an atomizer or syringe, at similar dosages. The peak plasma midazolam concentrations, measured approximately 10 min following intranasal administration, were compared between the groups. Results: No significant difference was observed in the plasma midazolam concentrations (ng/mL) between the syringe and atomizer groups (median and interquartile range: 148.8 [126.3-293.7] ng/mL versus 133.3 [76.4-176.3] ng/mL; p=0.414), as well as in the time from administration to sampling (8.0 [7.75-10.0] min versus 9.5 [6.75-10.0] min; p=0.710) or in weight-adjusted dose (0.48 [0.44-0.50] mg/kg versus 0.49 [0.47-0.56] mg/kg; p=0.414). Conclusion: This study is the first to validate the common Brazilian practice of using syringes alone for rapid nasal midazolam delivery during pediatric emergencies. Future studies should elucidate the clinical outcomes of this approach.

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ABSTRACT Objective: Clinical, imaging, and laboratory differentiation between non-functioning pituitary adenomas (NFPAs) and prolactinomas can be challenging in clinical practice because of their similar presentation and eventual overlap in prolactin levels. The degree of prolactin suppression after a single low-dose cabergoline administration may be useful as a test to discriminate between these two clinical conditions and to determine the choice of therapy (dopamine agonist versus neurosurgery). Methods: This retrospective cohort study included 19 patients with macroadenomas (11 NFPAs and 8 prolactinomas) whose prolactin levels were evaluated at baseline and 48 h after receiving a single dose of 0.25mg cabergoline. A receiver operating characteristic curve was generated for sensitivity and specificity analyses. Results: The baseline median prolactin level was 58ng/mL (range, 32.5-151.2ng/mL) in the NFPA Group, which was significantly lower than that observed in the Prolactinoma Group (733.7 [range, 180-6941ng/mL]) (p<0.001). After the cabergoline disconnection test, the NFPA Group exhibited a lower absolute prolactin level (p<0.001) and a higher percentage of prolactin reduction (p=0.004). The post-test prolactin level ≥26.3ng/mL had 100% sensitivity and specificity in identifying prolactinomas. When using the percentage of reduction, post-test prolactin reduction ≥85.6% had 54.5% sensitivity and 100% specificity to differentiate NFPAs from prolactinomas. Conclusion: A single low-dose oral cabergoline is a fast and inexpensive test for use in daily clinical practice to discriminate between hyperprolactinemia due to NFPAs and prolactinomas, with high sensitivity and specificity.

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ABSTRACT Objective: To develop and validate a comprehensive mobile health App (mHealth App) to increase the health literacy and care engagement of patients undergoing bariatric surgery. Methods: App development required identifying patient needs, conducting a literature review, benchmarking, and designing the App through a multi-professional team. A prototype was created and validated by healthcare and information technology specialists, and patients undergoing bariatric surgery. Results: The Baritrip App contained 188 screens divided into eight sections, covering clinical, surgical, nutritional, mental health, and speech therapy domains. The overall content validity index of the App as assessed by experts was 0.99. Bariatric surgery patients assessed the layout, language, content organization, and engagement of the App, with an overall agreement rate of 89.1%. Conclusion: The Baritrip mobile health App showed good content validity and cultural appropriateness for bariatric surgery patients.

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ABSTRACT Objective: This study aimed to evaluate the association between pre-transplant parathyroid hormone levels and renal function 1-year after kidney transplantation. Methods: This retrospective cohort study was conducted at a tertiary public university hospital and included all patients who underwent kidney transplantation between May 2012 and September 2020. Patients under 18 years of age and those who received a transplant from a living donor were excluded. The primary outcome was renal function at 1 year, as assessed using the CKD-EPI formula. Univariate and multivariate analyses were performed to identify predictors of graft function at one year clinical and laboratory variables. Results: During the study period, 1,128 kidney transplants were performed. After applying exclusion criteria, 382 patients from six dialysis centers were included in the final analysis. Pre-transplant parathyroid hormone levels were not associated with renal function in either univariate or multivariate analyses (p=0.968 and p=0.616, respectively). In the multivariate analysis, recipient age (Coefficient: −0.41, 95% CI= −0.63 to −0.20, p<0.001) and Kidney Donor Profile Index (Coefficient: −0.44, 95%CI= −0.54 to −0.33, p<0.001) were significantly associated with graft function at 1 year. Conclusion: Pre-transplant serum levels of intact parathyroid hormone levels were not associated with renal function 1 year after transplantation. Conversely, recipient age and Kidney Donor Profile Index showed significant associations with graft outcomes, highlighting the importance of individualized risk assessment in transplant evaluation.

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ABSTRACT Objective: To analyze the sociodemographic and clinical characteristics, comorbidities, therapeutic resources, and mortality rates of elderly patients with COVID-19 admitted to an intensive care unit. Methods: This retrospective cohort study included patients admitted to the intensive care unit of a large hospital in São Paulo, Brazil, from March 1, 2020, to March 31, 2021. Patients were categorized as adults (≥18 years) and elderly (≥60 years). Results: Of the 504 patients, 326 (64.7%) were elderly. Compared to the adults, elderly patients had significantly higher Simplified Acute Physiology Score 3 and Sequential Organ Failure Assessment scores on admission (p<0.001). They also had a greater prevalence of comorbidities, as reflected by a higher Charlson Comorbidity Index (p<0.001) and were frailer according to the Modified Frailty Index (p<0.001). The elderly group had a longer intensive care unit stay, with an average of 17±19 days and a hospital stay of 40±39 days, compared to the adults who had an average intensive care unit stay of 14±16 days and a hospital stay of 28±25 days. Hospital mortality was significantly higher among elderly patients (37.7%) than among adults (12.4%) (p<0.001), especially in those who developed acute kidney injury and required vasopressors and extracorporeal membrane oxygenation. The other independent risk factors for mortality were frailty, arrhythmias, and prior organ transplantation. Conclusion: Frail elderly intensive care unit patients with multiple comorbidities require more resources, have longer hospital stays, and face higher mortality rates. Early interventions targeting this population could improve survival.

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ABSTRACT Objective: To analyze the post-exercise effects of self-selected exercise intensity compared with the intensity recommended by guidelines on blood pressure and heart rate variability in participants with peripheral artery disease. Methods: This was a randomized crossover trial. Twenty participants with peripheral artery disease (52.6% men; 69.1±7.9 years; ankle-brachial index 0.59±0.15) underwent three experimental sessions: self-selected exercise intensity, intensity recommended by guidelines, and a control session (no exercise). Blood pressure (auscultatory method), heart rate, and heart rate variability were measured before and after the intervention. Results: Acute reductions in systolic blood pressure were observed in the exercise sessions compared to the control (p<0.005). The heart rate decreased after control and increased after exercise sessions (p<0.001). The absolute heart rate increase after exercise sessions were higher than that in the Control Group p<0.001. Heart rate recovery showed a progressive decrease post-session over 300 s (p<0.001), with the root mean square of successive differences significantly decreasing up to 60 seconds in both exercise sessions (p<0.05). Conclusion: Acute walking exercise sessions prescribed at self-selected exercise intensity had similar effects on reducing systolic blood pressure and heart rate recovery compared with walking exercise session performed at the guideline-recommended intensity. ClinicalTrials.gov Identifier: NCT04333615.

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ABSTRACT Objective: This study aimed to evaluate whether clinical, laboratory, and radiological data could effectively identify struvite stones without the need for crystallographic analysis. Methods: Stone fragments obtained using endourological procedures were subjected to crystallographic analysis. A prospective evaluation and comparison were conducted between patients with and without struvite stones. Sex, age, comorbidities, Hounsfield Unit Coefficient, stone size, urine culture, and urinary pH were analyzed. Results: Among the 221 stones enrolled, 18% were struvite. Among patients with struvite stones, 95% were women, whereas in the group without struvite stones, 51% were women. The average age was 40.6 years among patients with struvite stones, and 51.5 years in the other group (p<0.001). The stone size in the struvite group (24.9 mm) was significantly larger than that in the non-struvite group (15.6 mm) (p<0.001). The urinary pH was significantly higher in the struvite group than in the non-struvite group (p<0.001). Patients with a positive urine culture had a 3.78 times greater chance of having a struvite stone than those with a negative urine culture (p<0.01). Multivariate analysis considering pH, age, and stone size yielded an AUC value of 0.83, sensitivity of 0.39, specificity of 0.95, and accuracy of 0.85. There was no significant difference between the groups in terms of the Hounsfield Unit Coefficient and comorbidities. Conclusion: Our analysis further supports the conclusion that characteristics such as pH, age, stone size, and urine culture have notable specificity but low sensitivity for identifying struvite stones.

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ABSTRACT Objective: To compare mortality rates between sexes in a cohort of patients with intermittent claudication residing in a metropolitan city in Brazil. Methods: In this study, we included 215 patients (mean age 67±10 years, 65.3% men) who were followed for an average of 5.2 years (95% confidence interval [95%CI]: 4.8-5.5 years). At baseline, sociodemographic data, comorbidities, and clinical characteristics were recorded. The six-minute walk test was administered, with results reported as both absolute and relative walking distances, the latter based on reference values for healthy individuals with similar characteristics. Deaths were documented throughout the follow-up period. Cox regression analysis was used to estimate hazard ratios (HRs) and 95%CIs, adjusting for potential confounding factors. Results: A total of 105 patients (58.9% men) died, with cardiovascular diseases accounting for the leading cause of death (32.0%). Deceased patients were older, had a higher prevalence of hypertension, and demonstrated shorter absolute and relative walking distances. Men had a significantly higher risk of all-cause mortality compared to women, independent of age, chronic obstructive pulmonary disease, six-minute walking distance, and ankle-brachial index (HR: 2.774; 95%CI= 1.316-5.847). Conclusion: In patients with peripheral artery disease, men with intermittent claudication symptoms exhibit a higher risk of all-cause mortality compared to women. Future research should focus on identifying sex-specific risk factors associated with mortality in this population. Such insights are critical for developing targeted interventions aimed at reducing mortality, particularly among men with intermittent claudication in low- and middle-income countries.

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ABSTRACT Objective: This study aimed to evaluate the percutaneous preoperative localization of lung masses suspected to be nonpalpable with a wedge-shaped wire (Somatex® Lung Marker System). Methods: Patients underwent CT-guided lung mass localization with the Somatex® Lung Marker System prior to resection of pulmonary lesions by video-assisted thoracoscopy. The characteristics of the lung masses, complication profiles, histological analysis, and surgical success were reviewed. Results: Forty lung masses were percutaneously localized preoperatively in 38 patients. Eight patients did not have malignancies. Major complications were not observed. All lung masses were fully resected after preoperative localization. Conclusion: The findings support the feasibility and safety of the Somatex® Lung Marker System for the preoperative localization of lung lesions.

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ABSTRACT Objective: Posterior cervical spine surgery is used to decompress and/or stabilize the spine for the treatment of various spinal diseases. The aim of this study was to evaluate the clinical characteristics, surgical indications, and complications of patients who underwent posterior cervical spine surgery at a tertiary center. Methods: This retrospective cohort/case series study included data from patients who underwent posterior cervical spine surgery at a tertiary hospital to treat different cervical diseases. Results: A total of 161 patients were included. One hundred six (65.8%) patients were men, and mean age was 45.1 years. Patients with neoplastic diseases had the lowest mean age, whereas those with traumatic and degenerative diseases had the highest (p<0.001). Thirty-six patients (22.3%) experienced at least one complication. Serious adverse effects were infrequent despite six deaths (3.7%), and among the non-serious complications, surgical site infection (6.2%) and the need for late reoperation (4.3%) were the most common. No specific patient characteristics were associated with complications; however, a trend toward complications in urgent procedures was noted (p=0.085). Conclusion: Posterior cervical spine surgery was more common in men, and patients with degenerative diseases had a higher average age. There was no statistically significant association between complications and patient characteristics, with a trend toward more clinical complications during urgent procedures. Serious complications were infrequent in elective procedures; however, a small risk of death was noted, particularly in patients with trauma-related cervical spine injuries. Understanding the epidemiology and complications is fundamental for preoperative counseling and the prevention of complications.

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ABSTRACT Objective: To evaluate whether integrated palliative care is associated with improved overall survival and better end-of-life care in patients with upper aerodigestive tract malignancies. Secondary outcomes included the proportion of deaths in the intensive care unit, number of emergency department visits, chemotherapy use in the last 30 days of life, and the need for palliative sedation. Methods: This retrospective, non-randomized cohort study included patients with upper aerodigestive tract malignancies who died during a five-year period. Patients were categorized based on whether they received outpatient follow-up by a specialized palliative care team. Healthcare and clinical outcomes were compared between the two groups. Results: Among the 1,313 consecutive patients, 292 (22.2%) received outpatient palliative care. These patients had a median overall survival 4.7 months longer than those not followed up by palliative care. They also received less chemotherapy in the last 30 days of life, had fewer emergency department visits, had fewer intensive care unit deaths, and required less palliative sedation. Conclusion: Outpatient follow-up by a specialized palliative care team was associated with longer survival and better end-of-life care. These findings highlight the potential benefits of integrating palliative care earlier in the treatment of patients with upper aerodigestive tract cancers.

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ABSTRACT Objective: This study aimed to describe patient profiles and analyze costs, hospital stay, and mortality over the past 17 years. Methods: This ecological study was conducted using data available on TabNet, a DATASUS platform. Public data (from the government health system) on hallux valgus surgeries performed in Brazil between 2008 and 2024 were extracted. Sex, age, municipal region, costs, length of stay, and death rates were analyzed. Results: We analyzed 37,741 hallux valgus surgeries, of which nine (0.024%) resulted in death. Most participants were female aged 40–69 years, with a mean length of stay of 1.7 days. The total cost averaged US$ 141.53 per participant. Conclusion: Hallux valgus surgery is a safe procedure with a low total cost, a short length of stay, and a low mortality rate. Level of evidence 4, Case Series.

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ABSTRACT Introduction: In acute coronary syndrome, the release of inflammatory and myocardial injury biomarkers after percutaneous coronary intervention is associated with poor prognosis. However, little is known about the association between these biomarkers in patients with stable disease. Objective: We aimed to analyze the association between the systemic inflammatory response and myocardial injury after percutaneous coronary intervention in patients with chronic coronary syndrome. Methods: In this retrospective observational study, we collected blood sample data from 329 patients with chronic coronary syndrome before and 48 hours after successful percutaneous coronary intervention. Inflammatory biomarkers, including high-sensitivity C-reactive protein (CRP), white blood cells and subtypes, platelets, mean platelet volume, neutrophil-to-lymphocyte ratio, and platelet-to-lymphocyte ratio, were determined. High-sensitivity cardiac troponin I (hs-cTnI) was measured within 48 hours after percutaneous coronary intervention. Procedural myocardial injury was defined as an increase in hs-cTnI level without any new electrocardiographic changes or flow-limiting complications. Results: Percutaneous coronary intervention induced a systemic inflammatory response, with elevated levels of inflammatory biomarkers. Myocardial injury was detected in 66.7% of the patients. Spearman's rank-order correlation revealed an association between hs-cTnI and increased inflammatory biomarker levels: CRP 0.570 (p<0.001), neutrophil-to-lymphocyte ratio 0.190 (p<0.001), mean platelet volume 0.182 (p<0.001), platelet-to-lymphocyte ratio 0.180 (p<0.001), white blood cells 0.166 (p<0.001), neutrophils 0.145 (p<0.001), eosinophils 0.142 (p<0.001), lymphocytes −0.130 (p<0.001), monocytes 0.031 (p=0.344), and platelets −0.009 (p=0.778). Conclusion: Percutaneous coronary intervention in patients with chronic coronary syndrome induces a systemic inflammatory reaction, which is associated with myocardial injury.

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ABSTRACT Objective: To identify the factors associated with nursing workload with patients undergoing extracorporeal membrane oxygenation at 24 hours after initiation, as quantified using the Nursing Activities Score. Methods: This retrospective cohort study was conducted at an Extracorporeal Life Support Organization center in São Paulo, Brazil, and included adult patients who underwent extracorporeal membrane oxygenation between 2012 and 2023. Nursing workload was assessed using the Nursing Activities Score at intensive care unit admission and during the initial 24 and 48 hours of support. A linear regression model was used to identify factors associated with nursing workload during the initial 24 hours of support. Results: A total of 155 patients were included, with a mean age of 50.8±14.6 years, and 68.1% were male. The mean Nursing Activities Score at intensive care unit admission was 91.7%, increasing to 139.8% in the initial 24 hours of support, and slightly decreasing to 126.9% at 48 hours. The main factors associated with increased nursing workload during the initial 24 hours of extracorporeal membrane oxygenation were the presence of coronavirus disease 2019 (Estimate: 7.112; 95% confidence interval [95%CI]= 2.12-4.43; p=0.005) and the duration between intensive care unit admission and support initiation (Estimate: 2.890; 95%CI= 4.94-8.40; p=0.006). Conclusion: The nursing workload in the initial 24 hours of support was significantly elevated, influenced by clinical factors such as coronavirus disease 2019 and delayed support initiation. These findings highlight the need for structured care protocols and adequate nursing staff allocation to optimize patient outcomes and reduce excessive workload in extracorporeal membrane oxygenation management.

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ABSTRACT Objective To assess medical students’ attitudes, knowledge, opinions, and expectations regarding medical artificial intelligence solutions, according to their sex and year of study. Methods This cross-sectional survey was a single-center study conducted at a medical school in São Paulo, Brazil, using an online questionnaire. Results Of 145 medical students who completed the survey (female, n=108/145, 74%; age, 18-25 years, n=129/145, 89%), 71 (49%) classified their artificial intelligence knowledge as intermediate, 137 (95%) wished that artificial intelligence would be regulated by the government. If artificial intelligence solutions were reliable, fast, and available, 74% (107/145) intended to use artificial intelligence frequently, but fewer participants approved artificial intelligence when used by other health professionals (68/145, 47%) or directly by patients (26/144, 18%). The main benefit of artificial intelligence is in accelerating diagnosis and disease management (116/145, 80%) and problem is overreliance on artificial intelligence and loss of medical skills (106/145, 73%). Students believed that artificial intelligence would facilitate physicians’ work (125/145, 86%); increase the number of appointments (76/145, 53%); decrease their financial gain (63/145, 43%); and not replace their jobs but be an additional source of information (102/145, 70%). According to 88/145 (61%) participants, legal responsibility should be shared between the artificial intelligence manufacturer and physicians/hospitals. Conclusion Medical students showed positive perceptions of and attitudes towards artificial intelligence in healthcare. They presented interest in artificial intelligence and believed in its incorporation in daily clinical practice, if regulated, is user-friendly and accurate. However, concerns regarding this technology must be addressed.

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ABSTRACT Objective This study aimed to analyze the expression profiles of miR-23a and miR-146a in women with premature ovarian insufficiency and to evaluate their value as biomarkers of the disease for early diagnosis and prognosis, as well as effective therapies. Methods The global expression profiles of peripheral blood samples from 10 patients with premature ovarian insufficiency and 10 normovulatory women were analyzed for the targets miR-23a and miR-146a and the endogenous control miR-U6 using real-time quantitative polymerase chain reaction. Statistical analysis was performed using analysis of variance and Bonferroni tests for group analysis. Welch’s t-test was used to adjust for unequal variances between groups, and the Friedman test was used to confirm variance similarity. Results Increased miR-23a levels were observed in patients with premature ovarian insufficiency. An inverse correlation was observed for relative miR-146a expression, which showed decreased levels in the premature ovarian insufficiency group compared with the normovulatory group. The ratios of the relative expression levels of miR-23a and miR-146a significantly differed in the premature ovarian insufficiency group but not in the normovulatory group. These findings were reaffirmed by accuracy assessment, with a positive predictive value of 0.92. Conclusion Expression analysis of mir-23a and mir-146a demonstrates their potential use as biomarkers for premature ovarian insufficiency, owing to their relationship with the regulation of apoptosis and inflammation, follicular development, and cellular autoimmunity. This correlation can be assessed in larger sample sizes to confirm its importance in the early diagnosis, monitoring, and identification of potential therapeutic targets for premature ovarian insufficiency.

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ABSTRACT Objective This study evaluated the association between cognitive function and quantitative magnetic resonance imaging analyses, including brain volume, white matter hyperintensity volume, and diffusivity metrics. Methods This retrospective analysis included 504 older adults from São Paulo, Brazil, who underwent 3T magnetic resonance imaging scans. Image analysis was performed using the FMRIB Software Library (FSL), with peak width of mean diffusivity assessed via a public script. FLAIR signal changes were quantified using the Lesion Segmentation Tool and Fazekas scale. Cognitive performance was assessed using MMSE and 3MS tests. Multiple linear regression, adjusting for control variables, was used to evaluate the relationships between magnetic resonance imaging measurements and cognitive scores, validated against a UK Biobank sample. Results Magnetic resonance imaging demonstrated strong correlations with UK Biobank dataset. Fractional anisotropy, mean diffusivity, and peak width of the mean diffusivity values were significantly associated with white matter hyperintensities (Spearman’s rho: -0.630, 0.750, and 0.747, p<0.001). Specific brain regions demonstrated strong links between fractional anisotropy and mean diffusivity values and cognitive performance. Fractional anisotropy findings correlated positively with neuropsychological scores (r=0.315 for 3MS and r=0.285 for MMSE, p<0.001). Conclusion Diffusivity metrics, including fractional anisotropy, mean diffusivity, and peak width of the mean diffusivity significantly correlated with brain volume, white matter hyperintensities, and cognitive scores. These findings may serve as potential imaging markers for monitoring cognitive decline and dementia.

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ABSTRACT Objective This retrospective observational study analyzed satisfaction with a telehealth service in older individuals living in a metropolitan city in Brazil. Methods Sociodemographic, clinical, and telehealth service details (number of clinical appointments for each patient during a year) were collected. Satisfaction with the telehealth service was evaluated using the Questionnaire for the Evaluation of Patient Satisfaction Via Telemedicine (QAS-Tele) in 203 older individuals (59.1% women; 75.6±7.9 years old). A subanalysis was performed with patients divided into two groups: low score on QAS-Tele (first quartile) and high score on QAS-Tele (other quartiles). Results The questionnaire items and average total QAS-Tele score suggested high patient satisfaction (average total score of 4.71±0.54 out of 5). The patients with high QAS-Tele scores had a lower average age (74.4±7.8 versus 78.3±7.5 years, p≤0.001) and a higher proportion of individuals currently working (30.9% versus 9.4%, p≤0.001) and of individuals with four or more associated comorbidities (21.6% versus 0%, p≤0.001) than patients with the low QAS-Tele scores. Conclusion Patients in the present study reported high satisfaction with the telehealth service. Higher satisfaction with the telehealth service was reported by older adults in a younger age range, by individuals currently working, and by individuals who had a higher number of comorbidities. These findings suggest the importance of considering these factors in the planning of telehealth services in older individuals.

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ABSTRACT Objective Telemedicine via teleconsultations enhances access to specialized care. However, the degree of satisfaction among patients and providers with this method remains unclear. This study assessed patient and on-site physician satisfaction with the Comprehensive Specialist Teleconsultation Program (Telemedicine Expert Consultation) developed by Hospital Israelita Albert Einstein to reduce healthcare disparities in Brazil’s Northern and Central-Western regions. Methods A retrospective, single-center analysis employed the Net Promoter Score as the primary metric for evaluating satisfaction. Data were collected from patients and on-site physicians over three years through voluntary surveys with three focused questions. These assessed telemedicine effectiveness, fulfillment of patient needs, and satisfaction with project support. Additional analyses included response rates, demographics, and Net Promoter Score distribution across predefined performance zones. Results Of the 1,144 surveys distributed to physicians, 469 (41%) were received. Among the respondents, 459 (97.8%) either agreed or strongly agreed that patient needs were adequately met, and 462 (98.6%) expressed overall satisfaction, resulting in a three-year average Net Promoter Score of 91. For patients, 35,743 (32%) responses were obtained from 111,730 distributed surveys. Among patient respondents, 35,493 (99.3%) indicated that their needs were met, with 26,200 (73.3%) rating the service as “excellent,” with an average Net Promoter Score of 85 over the three years. Satisfaction scores from both groups fell within the Net Promoter Score “zone of excellence,” underscoring the program’s high performance in meeting expectations. Conclusion The Telemedicine Expert Consultation program successfully achieved high satisfaction rates among patients and on-site physicians.

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ABSTRACT Objective: This study aimed to investigate the effects of sex and time of day on behavioral parameters in healthy rats, focusing on locomotion, cognition, and memory (both spatial and episodic). Methods: Twenty-four Wistar rats (12 males and 12 females) were divided into morning and afternoon groups. Behavioral tests included actimetry for spontaneous locomotion, novel object recognition test for episodic memory, and the Morris water maze test for spatial memory. Data were analyzed cross-sectionally and longitudinally, considering sex and time of day as variables. The evaluated parameters included fast and slow horizontal and vertical movements, recognition index, average speed, and quadrant preference in the Morris water maze. Results: Females exhibited higher frequencies of rapid horizontal and vertical movements than males, especially in the morning. Novel object recognition test results showed higher recognition index values in the morning, with females displaying greater exploration of novel objects, while the Morris water maze test results indicated that the time spent in the target quadrant was consistent across groups, but females demonstrated longer latencies in the afternoon. Conclusion: These results highlight the significant influence of sex and circadian timing on behavioral performance in healthy animals. These factors should be carefully considered when designing and interpreting preclinical behavioral studies to improve experimental consistency and data reproducibility.

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ABSTRACT Objective: The aim of the present study is to assess whether the intensity of local inflammation relates to the presence of thin-cap fibroatheromas. Methods: Retrospective, single-center study of patients that underwent optical coherence tomography imaging and had either de novo or in-stent neoatherosclerosis. Intensity of macrophage accumulation and volume of neovascularization were measured for all lesions. Logistic binary regressions were used for uni- and multivariate analysis. Results: A total of the 92 lesions in 84 patients were selected. The degree of macrophage accumulation was higher in thin-cap fibroatheromas than non- thin-cap fibroatheromas lesions (5.0 versus 2.17; p<0.01). Neovascularization was more frequent in thin-cap fibroatheromas than non-thin-cap fibroatheromas lesions (87.5% versus 65.7%, p=0.04), and thin-cap fibroatheromas had a larger volume of neovascularization than non- thin-cap fibroatheromas plaques (92.2 versus 23.0 x 1000μm3/mm, p<0.01). At multivariate logistic analysis, neovascularization volume and degree of macrophage accumulation remained independently associated with thin-cap fibroatheromas. The dataset was divided according to the highest tercile of neovascularization volume (≥87.2 x 1000μm3/mm) and macrophage accumulation score (≥4.6). Plaques with low levels of neovascularization and macrophages were classified as thin-cap fibroatheromas in 14% of cases. Thin-cap fibroatheromas was present in 61.5% of plaques with high macrophagic and neovascularization content. Conclusion: Lesions with more macrophage accumulation and higher volumes of neovascularization are more likely to be thin-cap fibroatheromas.

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ABSTRACT Objective: We aimed to investigate the performance of an artificial intelligence (AI)-powered radiology platform for detecting pulmonary nodules on low-dose computed tomography of the chest compared with expert radiologists. The ancillary aims were to assess the Lung-RADS category agreement between the software and radiologists and to evaluate the percentage of missed lung nodules >6mm or those with inappropriate segmentation in the analysis performed by the AI software. Methods: This was a cross-sectional study. We evaluated low-dose computed tomography scans of 790 patients enrolled in a lung cancer screening program. All computed tomography scans were reviewed by an experienced team of thoracic radiologists (expert group). An AI algorithm analyzed the same set of scans independently, anonymously, and blinded to the computed tomography results (AI Group). The Lung-RADS classification system was used for both groups, and the reported findings were compared, considering expert analysis as the gold standard. Therefore, the accuracy results, negative and positive predictive values of AI, were measured. Results: The AI Group software showed high sensitivity (92.5%) and negative predictive value (97.8%) but low specificity (78.5%) and positive predictive value (50%). A significant number of subsolid nodules were missed in the AI group; however, none of them were >8mm (Lung-RADS 4). Conclusion: The AI software demonstrated a high negative and relatively low positive predictive values. The device appears to be an important adjunct, allowing the navigation team to prioritize examinations for clinically significant nodules.

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ABSTRACT Objective: We aimed to compare the radiological response in small hepatocellular carcinomas treated with radiofrequency ablation, percutaneous ethanol injection, and transarterial chemoembolization using the modified Response Evaluation Criteria in Solid Tumor radiological evaluation in patients on the waiting list for liver transplant. Methods: A retrospective analysis was conducted on 98 patients with uninodular tumors of 2–3cm, who were on the waiting list for liver transplantation and underwent radiofrequency ablation, percutaneous ethanol injection, or transarterial chemoembolization as bridging therapies. The patients underwent clinical and radiological follow-up and were assessed for necrosis and radiological response rates using control magnetic resonance imaging after 30–60 days. Results: Among the patients, 19, 25, and 54 were in the percutaneous ethanol injection, radiofrequency ablation, and transarterial chemoembolization groups, respectively. Most patients were male, had hepatitis C-induced liver disease, and exhibited a Child-Pugh A status. Imaging control evaluation showed that the radiofrequency ablation group had the highest necrosis rate (97.12%), followed by the percutaneous ethanol injection (77.05%) and transarterial chemoembolization (76.2%) groups (p=0.002). The radiofrequency ablation group showed the highest complete response rate (96%); the percutaneous ethanol injection and transarterial chemoembolization groups had 63.2% and 46.3%, respectively (p<0.001). Conclusion: Radiofrequency ablation resulted in a higher necrosis rate and superior radiological response than did percutaneous ethanol injection and transarterial chemoembolization in this study cohort.

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ABSTRACT Objectives: To describe the use of advanced life support, resource utilization, and clinical outcomes and to identify the risk factors for late initiation of palliative care support in patients at the intensive care unit. Methods: A retrospective, single-center cohort study conducted in a private intensive care unit. All patients aged ≥18 years in palliative care admitted to the intensive care unit between January 1, 2014, and December 31, 2018, were eligible. Patients were categorized based on the timing of palliative care initiation: Early Group (palliative care instituted before or within 24 h of intensive care unit admission) and Late Group (palliative care instituted after 24 h of intensive care unit admission). Comparisons were made between the two groups. Results: Overall, 502 patients were included in this analysis. The Early Group accounted for 37.6% (189/502) of patients and the Late Group for 62.4% (313/502). Patients in the Early Group were older, had a higher modified frailty index, and had lower rates of immunosuppression or hematologic cancers. During the intensive care unit stay, the Early Group required less mechanical ventilation, vasopressors, renal replacement therapy, red blood cell transfusions and parenteral nutrition compared to the Late Group. Additionally, the Early Group had lower intensive care unit and hospital stay and mortality compared to the Late Group. Independent predictors of late initiation of palliative care in the multivariate analysis included younger age, being a surgical patient, chronic kidney disease requiring renal replacement therapy, hematologic cancer, and the need for mechanical ventilation at intensive care unit admission. Conclusion: Early implementation of palliative care was associated with reduced resource utilization and improved clinical outcomes.

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ABSTRACT Objective: To develop a simple and accessible univariate tool based on tumor volume to predict 1-year mortality in patients with oral cavity squamous cell carcinoma. Methods: A retrospective analysis was conducted on patients with oral cavity squamous cell carcinoma included in the GENCAPO cohort. Tumor volume was calculated using the formula of Monga et al. Classification and regression trees were used to define risk categories after determining the volume cutoff points. Logistic regression using 1-year vital status (alive or deceased) as the outcome was employed to construct the Oral Neoplasm Clinical Outcome in 1 year (ONCO)-1 score. Model discrimination and calibration were evaluated using the area under the receiver operating characteristic curve and the Hosmer-Lemeshow test, respectively. After building the model, we compared it with the TNM system (8th edition) using Kaplan-Meier curves. Results: ONCO-1 showed good stratification ability, with a progressive increase in odds ratios for 1-year mortality: odds ratio 2.47 (G2), 4.01 (G3), and 9.99 (G4), compared to group G1. The model demonstrated good discrimination (area under the curve=0.7031) and excellent calibration (Hosmer-Lemeshow p=0.99978). Kaplan-Meier curves indicated a superior prognostic performance of ONCO-1 compared to TNM classification in predicting 1-year survival. Conclusion: Tumor volume proved to be a robust predictor of short-term mortality in oral cavity squamous cell carcinoma. ONCO-1 provided better 1-year risk stratification compared to TNM and may contribute to more individualized clinical decision-making.

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ABSTRACT Objective: This study aimed to analyze the effects of two proposed telerehabilitation interventions on the functional capacity of patients with chronic obstructive pulmonary disease. Methods: A randomized clinical trial was conducted with 60 patients of both sexes equally distributed into two groups: G1, submitted to a protocol of breathing exercises and health education; and G2, submitted only to health education. The interventions were performed remotely through videoconferencing with patients in their homes for 8 weeks. Results: When comparing the pre- and post-intervention moments of G1 and G2, significant differences were found in the functional capacity scores in both cases (p=0.0001), however, when comparing the post-intervention moment of the two groups, the improvement was more significant in G1 (p=0.0007). Conclusion: Both telerehabilitation with a respiratory exercise protocol associated with health education, and telerehabilitation with only a health education protocol are beneficial for the functional capacity of patients with chronic obstructive pulmonary disease. However, the telerehabilitation with a breathing exercise protocol associated with health education had a greater impact on the improvement of patients with chronic obstructive pulmonary disease.

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ABSTRACT Objective: To evaluate a simplified exercise program for patients with knee osteoarthritis in terms of pain, functionality, muscle strength, and quality of life. The correlation of serum levels of molecules and cytokines was evaluated after the exercise program. Methods: Overall, 47 patients with knee osteoarthritis participated in this single-arm interventional study. Outcomes were assessed using the Western Ontario and McMaster Universities Osteoarthritis Index, Quality of Life, Visual Analog Scale, Timed Up and Go functional test, and muscle strength assessment. Serum levels of molecules and cytokines were analyzed using enzyme-linked immunosorbent assays. Results: The program resulted in improvements in pain and physical function (0.21 points; 95%CI=-0.26; −0.17), Visual Analog Scale (1.50; 95%CI=-1.90; −1.10), EuroQol-5 Dimension 3-Level (0.16; 95%CI=0.100; 0.227), and Timed Up and Go test (0.40; 95%CI=-0.57; −0.23). Significant differences were noted in the isokinetic knee flexion peak torque (0.16; 95%CI=0.10; 0.22), isometric knee extension (0.31; 95%CI=0.20; 0.43), and flexion (0.18; 95%CI=0.12; 0.23) peak torques for osteoarthritis. However, there was no significant difference in serum biomarker levels after the program, and there was no correlation between serum biomarker levels and clinical improvement outcomes. Conclusion: The simplified exercise program for patients with knee osteoarthritis patients effectively improved pain, functionality, muscle strength, and quality of life. However, biomarkers do not provide evidence of clinical improvement. ClinicalTrials.gov Identifier: NCT02964624.

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ABSTRACT Objective: To assess the intra- and inter-observer reliabilities of cervical sagittal radiographic measurements performed by evaluators with varying levels of clinical experience. Methods: This study analyzed lateral cervical radiographs from 14 patients who had undergone single-level anterior cervical discectomy and fusion. Four evaluators, a spine surgeon, radiologist, spine surgery resident, and medical student, measured five sagittal alignment parameters (C2-C7 Cobb angle, T1 slope, cervical sagittal vertical axis, cervical sagittal vertical axis via C-shape, and T1- C2-C7 Cobb angle). Intra-observer variability was calculated as the deviation from the median measurements. Inter-observer reliability was assessed using intra-class correlation coefficients. Results: Intra-observer variability was lowest among experienced evaluators (13% for both the spine surgeon and radiologist) and highest for the medical student (19.4%). The intra-class correlation coefficients ranged from 0.54 to 0.96, indicating moderate to excellent agreement. When only the two most experienced evaluators were included in the analysis, intra-class correlation coefficients exceeded 0.88 for all parameters. Conclusion: Observer experience significantly influences the reliability of sagittal cervical radiographic measurements. Although less experienced evaluators demonstrate higher variability, their performance remains within acceptable limits. Standardized training protocols may help improve consistency across different levels of expertise.

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ABSTRACT Objective: To identify the costs pertaining to the preparation and administration process of each chemotherapy treatment session in a public oncology hospital belonging to the Brazilian Unified Health System. Methods: This prospective, observational, and descriptive study employs the bottom-up micro-costing method through Time-Driven Activity-Based Costing, from the perspective of the facilities of a chemotherapy department within a public oncology hospital. Results: A comprehensive overview of the flow related to outpatient antineoplastic therapy was elaborated through process mapping, which included each step required for a treatment session. Total personnel costs were calculated at R$ 287,66, distributed among the nursing (48.81%), pharmacy (18.66%), clinical analysis (16.27%), and clinical oncology (16.27%) sectors. The total cost of one intravenous antineoplastic therapy session per patient, excluding the cost of the antineoplastic drug, was R$ 470,35. Nursing care accounted for 49.88% (R$ 234,61) of the financial resources used per session, while pharmacy, clinical analysis, and clinical oncology accounted for 24.47%, 15.70%, and 9.95% of the costs, respectively. Conclusion: Employing the Time-Driven Activity-Based Costing method in health services not only facilitates resource optimization, providing quality and efficient care within constrained budgets, but also enhances control over processes and their financing.

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ABSTRACT Objective To conduct an ex-ante cost-benefit analysis of implementing Vendor Neutral Archive technology in the Brazilian Public Health System. Methods The cost-benefit analysis involves monetizing the potential costs and benefits of implementing Vendor Neutral Archive in the Brazilian Public Health System, focusing on comparing these values using the return on investment measure. Results The aggregate analysis at the Brazilian Public Health System level reveals that the estimated return on investment for the first year after Vendor Neutral Archive implementation is 5.63%, rising to 10.12% after three years. The results indicate a positive correlation between the number of imaging exams conducted and the financial gains for the health institution under analysis. A minimum number of approximately 11,500 exams is required to implement Vendor Neutral Archive technology to generate positive returns in the first year after implementation. Conclusion Despite the importance of interpreting results cautiously owing to assumptions and methodological limitations, the findings highlight the strategic significance of Vendor Neutral Archive in enhancing the efficiency and sustainability of the Brazilian Public Health System. Adopting cloud-based medical image storage requires a significant upfront investment but promises substantial benefits. Within the Brazilian Public Health System, the return on this investment can be realized in less than one year, correlated with the volume of imaging exams performed. This underscores the importance of scalability in the healthcare system, where wider adoption of Vendor Neutral Archive results in higher returns.

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ABSTRACT Objective: Considering the difficulties of Brazil's Public Health System in providing comprehensive care, the present article aimed to assess legal cases filed against the Brazilian Public Health System in pursuit of finer treatment for patients with prostate cancer. In doing so, this study aims to provide the intel necessary to support new public health policies, as well as to assess the financial impact on the Federation, thereby accounting for better outcomes in patient care. Methods: This cross-sectional study evaluated the technical notes issued by the Technical Support Centers of the Judiciary regarding lawsuits from patients against the Brazilian Public Health System from 2019 to 2024, concerning prostate cancer to better advise the formulation of public policies regarding oncologic care. Results: A total of 3,136 technical notes were issued. Lawsuits were intended to obtain either medication (88.6%), procedures (10.2%), or other healthcare products (1.2%). Most medications requested were Androgen Receptor Pathway Inhibitors in 2,470 cases, corresponding to approximately 88.9% of the demand for drugs and 78.8% of all treatment demands. Overall, abiraterone was the most requested intervention, accounting for 51.2% of the technical notes issued. As for the distribution of legal proceedings within Brazilian states, demands were more common in the Southern (42.2%), Northeastern (31.3%), Southeastern (14.1%), Central-western (11.5%), and Northern (0.86%) regions of Brazil. However, the Southeastern and Southern regions tend to pursue more expensive drugs. Conclusion: Therefore, there is a pressing need for strategic interventions to address the escalating healthcare litigation crisis in Brazil. Collaboration among government entities, the scientific community, the judiciary, and patient advocacy groups is essential for effective formulation.

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ABSTRACT Schizophrenia diagnostics have evolved to adapt to clinical needs and scientific advances, and the current denominations emerged at the beginning of the twentieth century. Most problems arise while integrating clinical experiences, based on historical psychopathological descriptions, with emerging translational neuroscience research. This study aimed to evaluate the state-of-the-art critics of the current schizophrenia concept and their recommendations for new concepts. We performed a narrative review of the literature and searched for studies published in English in PubMed in the last 2 years which discussed the diagnosis of schizophrenia. Two authors independently selected the studies after analyzing the abstracts. Subsequently, studies were selected for this review by consensus. Twenty-six studies were selected, and all authors, except two, had restrictions on the current categorical model for the diagnosis of schizophrenia owing to the heterogeneity of symptomatology and high frequency of comorbidity. Eight studies proposed changes to the concept of schizophrenia. The central proposition was to adopt psychotic syndrome as a core feature instead of the current concept of schizophrenia. We synthesize these proposals using psychosis as a spectrum that includes schizophrenia as a more severe case at the end of the spectrum.

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ABSTRACT Introduction Traumatic brain injury is a leading cause of death and disability. Tranexamic acid, an antifibrinolytic agent, holds the potential for managing intracranial hemorrhages secondary to traumatic brain injury. However, its efficacy and safety remain subjects of ongoing debate. Objective To better clarify the efficacy and safety of tranexamic acid in that context and to evaluate the need for further studies. Methods We conducted a comprehensive search of seven electronic databases, eight study repositories, and tertiary sources between January 2021 and 2022 for randomized controlled trials involving victims of traumatic brain injury aged 15 or older who received tranexamic acid versus placebo or standard care. The primary outcomes were all-cause mortality and hemorrhagic complications during treatment. This review incorporated elements of PRISMA guidelines, Cochrane’s Risk of Bias assessment, and GRADE to assess evidence quality. Sensitivity analyses were also conducted. Results Out of 6,958 references retrieved, 14 of the 17 randomized controlled trials were analyzed, encompassing a total of 15,017 patients. Analyses for all-cause mortality did not reach statistical significance (RR= 0.95, 95%CI= 0.88-1.02 | trial sequential analysis RR= 0.95, 95%CI= 0.87-1.03). However, the analysis of hemorrhagic complications during treatment showed statistical significance for progressive intracranial hemorrhage (RR= 0.82, 95%CI= 0.68-0.99 | trial sequential analysis RR= 0.82, 95%CI= 0.38-1.78). Analyses of secondary outcomes, namely unfavorable neurological outcome and other adverse effects, did not demonstrate statistical significance. Conclusion Tranexamic acid use did not demonstrate efficacy based on all-cause mortality but showed a favorable safety profile. Additional clinical trials may shed light on remaining clinical uncertainties. Prospero database registration: CRD42021221949.

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ABSTRACT Diabetes mellitus is a highly prevalent human endocrine disorder. Skin lesions are reported in approximately one-third of all diabetes mellitus patients. The clinical presentation and frequency vary according to the subtype of diabetes mellitus, metabolic control, and clinical course, with certain skin diseases occurring before diagnosing hyperglycemia. In this regard, the correct definition of cutaneous manifestations associated with diabetes mellitus can help define the etiology of hyperglycemia as well as the need to optimize glycemic control. In this narrative review, the most common cutaneous diseases observed in diabetes mellitus are discussed, including pruritus, acanthosis nigricans, necrobiosis lipoidica, bullosis diabeticorum, scleroderma diabeticorum, granuloma annulare, diabetic dermopathy, skin reactions due to device use, diabetic foot ulcers, recurrent cutaneous infections in diabetes mellitus and other dermatoses associated with hyperglycemia. The epidemiology, pathophysiology, differential diagnosis, and treatment of this disease are discussed. Therefore, knowledge and recognition of the most common dermatological lesions in patients with diabetes mellitus are essential for both endocrinologists and primary care physicians.

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ABSTRACT Background Child immunization plays a critical role in preventing numerous diseases. However, the COVID-19) pandemic has profoundly disrupted healthcare systems globally, including routine child vaccination programs. Objective To provide an overview of the reduction in vaccine coverage among infants and children during the pandemic and analyze the potential impacts of decreased child immunization during this period. Methods A comprehensive search was conducted using the MeSH terms “Child,” “Vaccination”, and “COVID-19,” along with their synonyms. Systematic reviews published between March 11, 2020, and June 1, 2023, in Portuguese or English were included. Databases searched included PubMed, BVS (Biblioteca Virtual em Saúde), Embase, and Scopus. Two blinded independent reviewers performed the selection process, with conflicts resolved by a third reviewer. The AMSTAR-II tool was used to assess the methodological quality of the included studies. Results Of the 1,534 eligible articles, only 13 addressed the pandemic’s impact on children’s vaccination coverage. Most studies involved multiple countries and reported a significant decrease in children’s vaccination coverage due to the COVID-19 pandemic. Conclusion The findings were heterogeneous but consistently highlighted the substantial impact of the COVID-19 pandemic on routine vaccination coverage in most countries. Further research is needed to explore the epidemiological consequences of disruptions to vaccination schedules, potentially guiding public policies and raising awareness about the importance of adhering to health protection programs.

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ABSTRACT Objective: To compare the effectiveness and safety of phacoviscocanalostomy and phacotrabeculectomy in treating combined glaucoma and cataracts. Methods: A systematic review and meta-analysis were conducted following the PRISMA guidelines. The PubMed, Web of Science, Cochrane, and Embase databases were searched for randomized controlled trials or observational studies comparing phacotrabeculectomy to phacoviscocanalostomy in patients with glaucoma and cataracts. Statistical analysis was used to compare the efficacy (intraocular pressure reduction, mean deviation of the visual field, and failure rates) and safety (general complication rate and rates of hyphema, hypotony, perforation, and intraocular pressure spikes) between the two procedures. Results: The study included 331 eyes from one randomized controlled trial and two non-randomized controlled trials, with 154 undergoing phacoviscocanalostomy and 177 undergoing phacotrabeculectomy. The results indicated no significant differences in surgical failure rates, mean deviation of the visual field, and intraocular pressure at one, three, six, and twelve months between the phacoviscocanalostomy and phacotrabeculectomy groups. Furthermore, although the overall complication rate between the two procedures showed no difference, the rate of intraocular pressure spikes was higher in patients who underwent phacoviscocanalostomy. Conclusion: Phacotrabeculectomy and phacoviscocanalostomy are effective treatments for glaucoma and cataracts. Prospero database registration: (www.crd.york.ac.uk/prospero) under ID CRD42024502391.

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ABSTRACT Objective To evaluate the prevalence of autoimmune diseases in patients with type 1 diabetes mellitus. Methods This scoping review was conducted following the Joanna Briggs Institute guidelines and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) tool to ensure methodological rigor. We systematically searched PubMed, Embase, Scopus, Lilacs, and Web of Science databases to identify relevant literature published between 2018 and 2023. Results Twenty-four studies were included, mostly single-center studies from six continents, with varying study designs: 16 cross-sectional, seven retrospective, and one prospective cohort. The most prevalent autoimmune diseases found among patients with type 1 diabetes mellitus enrolled in these studies were autoimmune thyroiditis (5.5-41.2%), celiac disease (0.45-24.8%), rheumatoid arthritis (0.4-5.1%), and primary adrenal insufficiency (0.6-2.6%). Conclusion Autoimmune thyroiditis and celiac disease were the most prevalent autoimmune diseases in patients with type 1 diabetes mellitus. As the complexity of managing type 1 diabetes mellitus increases in the presence of multiple autoimmune comorbidities, further studies are required to elucidate the relationship between type 1 diabetes mellitus and different autoimmune pathologies. A deeper understanding of these associations will guide the development of public health policies, screening strategies, and educational initiatives tailored to the specific needs of this population.

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ABSTRACT Purpose of review Coronary artery bypass grafting, revascularization by percutaneous coronary intervention, and heart valve surgery are crucial therapeutic interventions for patients with various cardiovascular diseases. The objective of this literature review was to present the main evidence and practical aspects of the perioperative management of patients undergoing coronary artery bypass grafting and heart valve surgery. Recent findings Despite advancements in surgical and anesthetic techniques, coronary artery bypass grafting and heart valve surgery present significant risks for perioperative complications and death. These complications increase morbidity, mortality, and length of hospital stay. Coronary artery bypass grafting is indicated for patients with significant left main or advanced coronary artery disease. Most patients undergoing coronary artery bypass grafting with a reasonable life expectancy are advised to adopt a multiple-arterial graft strategy using two or three arterial grafts. Revascularization by percutaneous coronary intervention is frequently performed to alleviate symptoms in patients with stable angina and coronary artery stenoses causing moderate or severe ischemia. Intraoperative coagulation management should include tranexamic acid after the induction of anesthesia and protamine immediately after the termination of extracorporeal circulation. The prophylactic use of fresh-frozen plasma, desmopressin, recombinant activated factor VII, or fibrinogen to reduce bleeding is not recommended. Inhaled anesthetics have recognized cardioprotective properties; however, it is unclear whether anesthesia with a volatile agent can reduce mortality in patients undergoing elective surgery. Echocardiography plays an important role in the perioperative management of patients by defining myocardial structure, assessing intracardiac blood flow, aiding preoperative evaluation, facilitating intraoperative monitoring, and providing real-time guidance for intervention. The perioperative management of patients undergoing coronary artery bypass grafting, percutaneous coronary intervention, and heart valve surgery is highly complex and involves numerous specific conditions. Effective management requires dedicated multidisciplinary teams skilled in timely recognition, prevention, and treatment to ensure appropriate care.

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ABSTRACT Incidentalomas are lesions incidentally identified in patients undergoing imaging for unrelated reasons. Breast incidentalomas have a high correlation with malignancy, occurring in over 40% of cases. Consequently, their interpretation poses significant challenges for radiologists who must discern the findings that may present a potential risk to the patient. This pictorial review presents different incidental breast lesions revealed through cross-sectional imaging. We further review key concepts related to such incidentalomas.

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ABSTRACT Objective To systematically review and analyze studies investigating the efficacy and safety of inspiratory muscle training in adult chronic critically ill patients. Methods The MEDLINE, Embase, CENTRAL, LILACS, Clinical Trials Registry, and World Health Organization databases were queried on November 24, 2022 and January 22, 2025. The review was conducted in accordance with the PRISMA guidelines. RevMan V5.4 was used to analyze mean differences or standardized mean differences and 95% confidence intervals (95%CIs) for continuous variables and risk ratios with 95%CIs for dichotomous outcomes. The primary outcomes were inspiratory muscle strength, duration of mechanical ventilation, and severe adverse events; the secondary outcomes were hospital and intensive care unit mortality, intensive care unit and hospital lengths of stay, pulmonary function, non-serious adverse events, respiratory muscle mass, and functional status. Results Seven studies (n=390 participants) were included in the analysis. There was a significant increase in inspiratory muscle strength with inspiratory muscle training versus usual care (mean difference, -8.37; 95%CI= -15.21 to -1.52), although the certainty of evidence was very low; when compared with sham interventions, there was no significant difference (mean difference, -4.26; 95%CI= -14.05 to 5.53), also with very low certainty of evidence. The results for pulmonary function, duration of mechanical ventilation, and mortality were imprecise, with very low certainty of evidence. The available evidence also indicates the potential safety benefit of inspiratory muscle training, although the certainty of evidence remains very low. Conclusion: We identified that inspiratory muscle training may improve inspiratory muscle strength, with little to no difference on duration of mechanical ventilation, pulmonary function and severe and non-serious adverse events, when compared to sham inspiratory muscle training and usual care. However, the certainty of the evidence is very low. Evidence regarding the impact of inspiratory muscle training on intensive care unit mortality and length of stay is uncertain. Prospero database registration ID CRD42022370750.

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ABSTRACT Teachers have the significant potential to facilitate alterations in the teaching-learning process that can positively affect student outcomes. In the healthcare field, exposure to effective teachers is associated with enhanced clinical performance and student knowledge. The literature explores several characteristics that increase the possibility of obtaining better outcomes when developed by teachers. These features are described from the perspectives of students, managers, and teachers. However, when considering teacher development programs, it is necessary to translate these characteristics, skills, and personality traits into competencies for training and enhancement. Therefore, in this review, we propose eight primary competencies that encompass the majority of these previously described characteristics: knowledge, communication skills, empathy, ability to facilitate engagement, preparation, organization, ability to assess learning progress, self-reflection, and continuous enhancement. All of these are trainable. However, teacher training is a complex and continuous process. Understanding these competencies is crucial for designing effective teacher development programs that offer measurable outcomes, reinforce teaching adherence, optimize enhancement timelines, and reduce institutional costs. This review discusses each of the eight competencies, their interrelationships, and their effects on healthcare education, offering a foundation for teachers and managers to facilitate educational excellence.

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ABSTRACT Objective: The purpose of this systematic review with meta-analysis was to compare the short-term (≤1 month) effects of remote ischemic conditioning versus sham remote ischemic conditioning on vascular function in patients with cardiovascular diseases. Methods: A systematic review was conducted to identify relevant studies through six healthcare science databases up to March 2025. Arterial stiffness and endothelial function were defined as the primary outcome. Meta-analyses were performed using a random-effect model. Also, GRADE Pro software was used to evaluate the quality of evidence. Results: A total of 7 randomized clinical trials with 603 patients with cardiovascular diseases were included in the systematic review. Also, we included 5 studies in the meta-analysis. Compared with sham remote ischemic conditioning or control, short-term remote ischemic conditioning resulted in enhanced endothelial function (MD=4.22% [95%CI=1.75; 6.69]; p=0.0008; I2=0%) without any changes in arterial stiffness, (MD=-0.05 m/s [95%CI =-0.77, 0.67]; p=0.89; I2=89%). Conclusion: This systematic review and meta-analysis found that short-term remote ischemic conditioning was associated with improvements in endothelial function compared with sham remote ischemic conditioning or control in cardiovascular patients, without any impact on arterial stiffness. Prospero database registration: ID CRD42021234702.

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ABSTRACT Introduction: Cataracts are the leading cause of reversible blindness worldwide, with age-related cataracts being the most common type. With advancements in digital workflows, new alternative surgical processes aim to enhance efficiency and patient outcomes. Objective: This study aimed to evaluate the effectiveness of digital versus manual workflows for cataract surgery through a systematic review and meta-analysis focusing on preoperative assessment time, surgery planning time, intraoperative duration, and transcription frequency. Methods: The study was performed in accordance with PRISMA guidelines and identified relevant studies published until July 2024 in the PubMed, Embase, Web of Science, and Cochrane databases. Results: Digital workflows significantly reduced preoperative assessment and intraoperative times for astigmatic cataracts (mean difference (MD)=80.94 s, p<0.01; MD=107.13 s, p=0, respectively) and planning times (MD=130.52 s, p=0.43). Additionally, digital workflows decreased transcription requirements for conventional and post-refractive cataracts. Heterogeneity was notable, especially in the preoperative assessments (I2 >90%). Conclusion: The findings suggest that digital workflows for cataract surgery improve efficiency; however, further large-scale, long-term studies are required to assess the broader applicability and cost-effectiveness of these workflows. Digitalization has the potential to streamline the surgical management of cataracts and enhance patient outcomes. Prospero database registration: ID CRD42024590552.

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ABSTRACT Introduction: The controversy surrounding the potential benefits of the basic saline solution vs. Ringer's lactate solution for patients undergoing phacoemulsification for cataracts prompted a systematic review and meta-analysis for comparing the two solutions. Objective: This systematic review and meta-analysis aimed to compare the basic saline solution with Ringer's lactate for irrigation in phacoemulsification for cataracts. Methods: We searched the Embase, PubMed, and Cochrane databases for randomized controlled trials comparing basic saline solution with Ringer's lactate in relation to central corneal thickness and loss of endothelial cell density after elective cataract surgery. Results: Four studies involving 322 patients who underwent phacoemulsification were included in the analysis. Of the participants, 161 (50%) received Ringer's lactate as the irrigation solution, and 161 (50%) received basic saline solution. No differences were noticed between Ringer's lactate and basic saline solution regarding the loss of endothelial cell density within 28 days. Conclusion: In patients undergoing phacoemulsification for cataracts, no significant differences in the loss of endothelial cell density and changes in central corneal thickness were observed between groups irrigated with Ringer's lactate and balanced salt solution. Prospero database registration: ID CRD42024554821.

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ABSTRACT Introduction: Acute kidney injury is a common and serious condition in critically ill patients. Current biomarkers, such as serum creatinine, are limited in early detection and prognostic assessment. The neutrophil-to-lymphocyte ratio has emerged as a promising inflammatory biomarker, reflecting systemic inflammation and potentially serving as a tool for risk stratification in high-risk groups. Objective: To evaluate the prognostic value of the neutrophil-to-lymphocyte ratio in predicting mortality in patients with acute kidney injury through a systematic review and meta-analysis. Methods: A comprehensive search was conducted in PubMed, Embase, Cochrane, and LILACS databases for full-text articles published from the inception of each database until June 2024, using terms related to neutrophil-to-lymphocyte ratio and acute kidney injury. Studies were included if they evaluated the relationship between neutrophil-to-lymphocyte ratio and mortality in acute kidney injury patients. Data were pooled for meta-analysis using a random-effects model, with sensitivity, specificity, and area under the curve (AUC) calculated. Results: Of the 806 studies identified, five met the inclusion criteria, encompassing a total of 2,424 patients. The pooled sensitivity and specificity of the neutrophil-to-lymphocyte ratio for predicting mortality were 0.58 (95%CI=0.51–0.65) and 0.65 (95%CI=0.59–0.71), respectively. The AUC was 0.65, suggesting moderate predictive power. Significant heterogeneity was observed across studies owing to differences in neutrophil-to-lymphocyte ratio cutoff points, patient populations, and outcomes analyzed. Conclusion: An elevated neutrophil-to-lymphocyte ratio is associated with a worse prognosis in patients with acute kidney injury, highlighting its potential as a readily available biomarker for risk stratification. Prospero database registration: CRD42024569162.

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ABSTRACT Objective: To evaluate the diagnostic accuracy of optical coherence tomography angiography for the identification of choroidal neovascularization in age-related macular degeneration. Methods: This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 recommendations. A literature search of the PubMed/MEDLINE, Scientific Electronic Library Online (SciELO), EMBASE, Cochrane Library, CAPES Periodicals, and LILACS scientific databases was conducted to identify relevant full-text articles published in English and Portuguese from January 2012 to January 2025. To comprehensively evaluate the effectiveness and the performance of optical coherence tomography angiography in terms of sensitivity and specificity, fundus fluorescein angiography (the gold standard for detecting choroidal neovascularization) was used as the comparator. The Quality Assessment of Diagnostic Accuracy Studies (QUADAS) 2 tool was used to assess methodological quality and risk of bias. Results: Eleven articles were included in the systematic review. The patients’ mean age ranged from 58.5 to 79.7 years. The sensitivity ranged from 50.0% to 94.0%, and the specificity ranged from 67.6% to 100.0%. The risk of bias was low, and the methodological quality of the studies was good, suggesting that optical coherence tomography angiography holds promise for the diagnosis of choroidal neovascularization. Conclusion: Optical coherence tomography angiography exhibited high sensitivity and specificity, demonstrating its potential for the detection of choroidal neovascularization in patients with age-related macular degeneration. However, current scientific evidence suggests that optical coherence tomography angiography is not superior to fundus fluorescein angiography and should not be used as a substitute. Extended and affordable protocols to analyze different subtypes of choroidal neovascularization and the performance of optical coherence tomography angiography devices should be evaluated. Prospero database registration: CRD420251046669.

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ABSTRACT Thalidomide exerts immunomodulatory properties that may be used to treat various conditions. Although its effectiveness in treating Crohn's disease in pediatric patients has been reported, its safety for off-label use is not well established. This study aimed to analyze the efficacy and safety of thalidomide in children and adolescents with inflammatory bowel disease, specifically Crohn's and ulcerative colitis. A narrative review of clinical trials and observational studies published between January 2001 and May 2023 that investigated thalidomide use in pediatric patients with Crohn's or ulcerative colitis was conducted. The results of clinical trials showed statistically significant remission rates and clinical improvement in patients. The most reported adverse event was peripheral neuropathy, resulting in discontinuation of medication in some cases. Other adverse effects, such as sedation, constipation, dizziness, and allergic reactions, were observed but were not serious. Thalidomide can be considered an alternative treatment option for pediatric patients with refractory inflammatory bowel disease. However, monitoring for peripheral neuropathy and potential dose adjustments are necessary. No new or unknown adverse reactions related to the medication were identified in this review.

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ABSTRACT Atherosclerosis remains the leading cause of mortality worldwide. The characterization of atherosclerotic lesions reveals that they represent a chronic and progressive inflammatory condition affecting the arterial wall. Despite extensive investigations, its complex pathogenesis remains incompletely understood. Single-cell RNA sequencing (scRNA-seq) has recently emerged as a transformative tool, enabling detailed analysis of the cellular composition within atherosclerotic plaques. This approach provides a more comprehensive and nuanced understanding of plaque biology. This review provides a concise overview of current scRNA-seq methodologies and highlights their applications in atherosclerosis studies to elucidate the mechanisms underlying its onset, progression, and potential therapeutic targets.

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ABSTRACT Food allergies are the leading cause of anaphylaxis in children. Cofactors, such as exercise and non-steroidal anti-inflammatory drugs, may influence the occurrence and severity of allergic reactions to food. However, despite their relevance, the underlying mechanisms of cofactor-enhanced food allergies remain poorly understood. We report the case of a 12-year-old girl with mitochondrial DNA depletion syndrome who was referred to an allergy appointment due to suspected ibuprofen hypersensitivity. Detailed anamnesis, laboratory assessment, and negative drug challenge results excluded this diagnosis; however, continued follow-up revealed a crucial pattern on patient reactions that led to the diagnosis of a cofactor-enhanced food allergy with the presumed involvement of soy storage proteins and non-steroidal anti-inflammatory drugs. Our purpose was to highlight the non-negligible role of cofactors in food allergies and the importance of early identification. Moreover, to underscore the relevance of maintaining patient follow-up, as new information may arise and redirect the diagnosis.

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ABSTRACT Kabuki syndrome is a rare congenital malformation with typical facial features, skeletal anomalies, delayed neuropsychomotor development and growth, and cardiac, genitourinary, gastrointestinal, endocrine, and dental anomalies. One of the main differential diagnoses is CHARGE syndrome, standing for and characterized by Coloboma of the eye, Heart defects, Atresia of the nasal choanae, Restricted intellectual development, Genitourinary malformations, and Ear anomalies. Because these syndromes have similar characteristics, distinguishing them may be challenging. A 24-year-old male patient admitted with reduced renal function had a previous phenotype-based diagnosis of CHARGE syndrome based on many characteristic clinical features. The unveiling of a hypocalcemic crisis diagnosed as primary hypoparathyroidism at the age of 15 years, which did not fit into that diagnosis, led the nephrologist to request a genetic test, which evidenced a missense variant of uncertain significance in exon 38 of the KMT2D gene. This phenotype further suggested Kabuki syndrome, ruling out CHARGE. The present report highlights the importance of genetic testing and discusses phenotype-genotype correlations, which ultimately showed that specific variants in exon 38 rendered a form of Kabuki syndrome distinct from the typical one.

Abstract in English:

ABSTRACT Dengue, a vector-borne acute febrile illness caused by members of the Flavivirus genus, has dramatically increased its occurrence worldwide. Neurological complications of dengue range from 2.63 to 40%, and subarachnoid hemorrhage is a rare, but significant manifestation. Hemophagocytic lymphohistiocytosis is a life-threatening hyperinflammatory syndrome, sometimes secondary to infections such as dengue. This report presents a rare case of severe dengue with subarachnoid hemorrhage and hemophagocytic lymphohistiocytosis. A 19-year-old male presented with a 7-day history of fever and myalgia, followed by severe headache and vomiting. Initial examination revealed high fever, hepatosplenomegaly, and pancytopenia. Lumbar puncture confirmed via computed tomography showed a Fisher Grade 2 subarachnoid hemorrhage with a small aneurysm at the junction of the left anterior coronary and anterior communicating arteries. Secondary hemophagocytic lymphohistiocytosis was diagnosed based on the criteria from 2004, with elevated inflammatory markers, hypertriglyceridemia, and hyperferritinemia. The patient was treated conservatively with intravenous fluids, osmotic diuretics, antiepileptics, steroids, and nimodipine. The patient showed clinical improvement and was discharged on the 11th day. Isolated subarachnoid hemorrhage is rare in dengue. The hyperinflammatory state in hemophagocytic lymphohistiocytosis, which is often overlooked due to nonspecific symptoms, can lead to aneurysm formation and rupture. Persistent fever, cytopenia, and hyperferritinemia should raise suspicion of hemophagocytic lymphohistiocytosis in cases of severe dengue with neurological complications. In patients with severe dengue and intracranial hemorrhage, clinicians should remain cautious for hemophagocytic lymphohistiocytosis to reduce the associated morbidity and mortality.

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ABSTRACT Azacitidine is a hypomethylating agent recommended for the treatment of patients with high-risk myelodysplastic syndromes. Here, we report the case of a patient with myelodysplastic syndrome who was not eligible for allogeneic stem cell transplantation (allo-SCT) and presented with a rare and previously unreported cutaneous side effect after the use of subcutaneous azacitidine. We propose that changing the route of azacitidine administration from subcutaneous to intravenous could potentially decrease the occurrence of bullous pemphigoid-like localized toxic reactions in some patients.

Abstract in English:

ABSTRACT A 49-year-old woman presented with a 16-year history of burning pain, warmth, redness, and edema in both toes, feet, legs and calves. Despite extensive medical testing, including genetic analysis, no specific cause was identified. Initial treatments failed to improve symptoms, leading to impaired quality of life and mental health. Eventually, a six-month course of intravenous immunoglobulin therapy provided complete relief, allowing the patient to resume normal activities. Erythromelalgia is a rare neurovascular condition characterized by pain, warmth, and erythema in the extremities. It can manifest as primary, inherited or sporadic, or secondary to underlying conditions, such as hematological neoplasms. Although genetic studies suggest a pivotal role of a gain-of-function mutation in the Nav1.7 voltage-gated sodium channel in familial cases, the pathogenesis underlying sporadic adult-onset cases remains uncertain. The frequent coexistence of autoimmune connective tissue diseases and the expanding evidence supporting immunotherapies in idiopathic small-fiber neuropathies underscores the possible involvement of adaptive immunity in such conditions. Given the potential complications in untreated patients, risks associated with long-term opioid therapy, and the absence of disease-modifying strategies, intravenous immunoglobulins may offer a more effective approach to pain control than conventional pain relievers, representing a promising direction for understanding the pathogenesis of erythromelalgia.

Abstract in English:

ABSTRACT The etiologies of vulvar nodules range from infectious to neoplastic. Owing to the wide spectrum of vulvar diseases, clinical differentiation of the lesions is crucial for adequate diagnosis and management. A 46-year-old patient presented with a nodular lesion in the vulvar region that had been growing slowly for 10 years. Gynecological examination revealed the presence of a solid nodular lesion measuring approximately 3 cm in the middle third of the right labia majora without phlogistic signs or secretion discharge. The lesion was excised and an anatomopathological study revealed a nodular hidradenoma. Nodular hidradenoma is a rare benign neoplasm of the apocrine glands that mainly affects women between 30 and 60 years of age. Although generally asymptomatic, some symptoms have been described, such as itching, pain, ulceration, or secretory discharge. The diagnosis was made by an anatomopathological study, and treatment consisted of total excision of the lesion without the need to enlarge the margin. During the investigation, malignant lesions such as liposarcoma of the vulvar region and non-melanoma skin cancers were excluded. Differential diagnosis is important because it requires a more invasive approach and surgical margins. This report aimed to expand the knowledge of the diagnosis of vulvar hidradenoma to exclude the possibility of malignant neoplasia while caring for vulvar nodules, thereby allowing proper management of the case.

Abstract in English:

ABSTRACT Moebius Syndrome is a genetic condition that results in inability for facial mimicry due to palsy of cranial nerves VI and VII. Syringomyelia is characterized by a dilation of the central canal in the spinal cord, and is generally asymptomatic. Both disorders are diagnosed using imaging tests. A newborn with no facial movements upon physical examination was admitted to the delivery room of our hospital. A specialist confirmed the condition to be Moebius Syndrome. Further investigation using magnetic resonance imaging indicated that syringomyelia was associated with Moebius Syndrome. Given that syringomyelia is a silent myelopathy with a possible impact on the future health of the patient, careful analysis is recommended when diagnosing Moebius Syndrome. Few similar cases have been reported to date. Further studies are warranted to determine the actual association between these two conditions. Since syringomyelia diagnoses are often made when testing for other conditions, as in this study, neurological examinations of the brain should be expanded to include the spinal cord, in order to verify the presence of coexisting disorders.

Abstract in English:

ABSTRACT Fungal infections have become a public health problem owingdute to their progressive increase in recent decades and high morbidity rates. Fungal bone and joint infections result from direct inoculation, contiguous infection spread, or hematogenous seeding of organisms. Trichosporon spp. are yeast-like basidiomycetes, with Trichosporon asahii being the most common pathogenic species. This article describes a rare case of tenosynovitis caused by Trichosporon asahii in an immunocompetent patient. Treatment with voriconazole resulted in an excellent clinical response.

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ABSTRACT Chryseobacterium indologenes is a Gram-negative aerobic bacillus commonly found in nosocomial environments, particularly in patients with prolonged hospital stays or those requiring long-term invasive devices. It primarily affects elderly and immunocompromised individuals. This microorganism is associated with multidrug resistance, which is a crucial factor in treatment decisions. Here, we report a case of C. indologenes infection in an infant following the ingestion of milk formula diluted with untreated water.

Abstract in English:

ABSTRACT Mycoplasma-induced rash and mucositis is a distinctive subset of reactive infectious mucocutaneous eruption identified in 2015 to differentiate it from other mucocutaneous disorders such as Stevens-Johnson syndrome, erythema multiforme major, and toxic epidermal necrolysis. Although its pathophysiology is not completely understood, Mycoplasma-induced rash and mucositis is characterized by polyclonal B cell proliferation, production of antibodies against Mycoplasma pneumoniae, subsequent immune complex deposition, and keratinocyte apoptosis. Clinical manifestations include scattered cutaneous lesions and severe mucositis, which predominantly affect children and young males. In this report, we present the case of a 4-year-old boy with characteristic Mycoplasma-induced rash and mucositis symptoms, including erythematous annular lesions, mucosal involvement, and positive serologies for Mycoplasma pneumoniae and herpes simplex. The diagnostic challenges, treatment modalities, and differential diagnosis of erythema multiforme major are discussed. Our case underscores the importance of recognizing Mycoplasma-induced rash and mucositis as a distinct entity, facilitating accurate diagnosis and tailoring management strategies to optimize patient outcomes.

Abstract in English:

ABSTRACT Polymethylmethacrylate is a microsphere-based plastic used in aesthetic procedures. However, it can cause granuloma formation and severe hypercalcemia, often accompanied by renal impairment, which is a significant concern. Despite increasing reports, there is no standardized treatment approach for polymethylmethacrylate-induced hypercalcemia, and its incidence remains underreported. In this study, we present three cases of polymethylmethacrylate users who developed severe hypercalcemia that was resistant to conventional treatments, resulting in deteriorating renal function. These patients achieved symptom control with cinacalcet, a medication primarily used to treat secondary hyperparathyroidism, severe primary hyperparathyroidism, and parathyroid cancer.

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ABSTRACT The increasing use of videolaparoscopy for the complete excision of endometriotic lesions and restoration of pelvic anatomy has helped improve long-term outcomes. However, risks remain, including rare but significant complications such as salpingoureteral fistulas. Early diagnosis using imaging methods enables adequate treatment and reduces the risk of new complications. In this report, we present a case of uretero-fallopian fistula following gynecological surgery for the resection of endometriotic lesions, with intraoperative inadvertent ureteral injury. This case report aimed to highlight the importance of diagnostic imaging in postoperative complications of gynecological surgeries for endometriosis, especially if inadvertent injuries occur during the procedure, and to guide the medical community in suspecting and addressing this condition.

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ABSTRACT This article describes the occurrence of cardiac tamponade in a premature newborn after the use of a peripherally inserted central catheter at a university hospital in Brazil. Pericardiocentesis was performed, the catheter was repositioned using radiography, and minimal residual pericardial effusion was confirmed using echocardiography. The patient showed good progress and was discharged from the hospital on day 47 of life without any complications related to the event. Therefore, although adverse events may occur following the insertion of peripherally inserted central catheters, imaging examinations and exclusion diagnoses have a positive impact on clinical outcomes. This study emphasizes the importance of a multidisciplinary team for monitoring and managing adverse events and optimizing the care of critically ill newborns.

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ABSTRACT Myopericytomas are perivascular myoid neoplasms that rarely exhibit malignant characteristics. They usually arise in the dermis or subcutaneous tissue and exceptionally involve deep soft tissues, with spinal localization being rare. We report the case of a previously healthy 32-year-old pregnant woman who presented with pain in the interscapular region and progressive loss of lower limb strength. Magnetic resonance imaging revealed a solid neoplastic mass at the T3 level, with spinal canal invasion and spinal cord signal abnormalities. The pregnancy was terminated, followed by lesion embolization, decompressive laminectomy, and local radiotherapy. The patient completely recovered from her neurological symptoms. Thoracic spine myopericytomas are rare and have been poorly reported in the literature. No studies have described the aforementioned neoplasm in a pregnant patient. We report this case because of its peculiarity, evolution, and outcome.

Abstract in English:

ABSTRACT Hypothyroidism is most frequently caused by Hashimoto's thyroiditis. While thyrotropin receptor antibodies are well-known in Graves’ disease-induced hyperthyroidism, their role in hypothyroidism is emerging. We report the case of a 37-year-old woman with facial and periorbital edema, weight gain, and hoarseness suggestive of hypothyroidism. Elevated thyroid stimulating hormone (TSH; 131mIU/L) and decreased free thyroxine (0.2ng/dL, 2.6pmol/L) levels confirmed this diagnosis. Laboratory findings showed dyslipidemia, impaired renal function, elevated creatine phosphokinase levels, and anemia. Despite negative results for thyroid peroxidase (TPO-Ab) and thyroglobulin (TgAb) antibodies, positive thyrotropin receptor antibodies (11IU/L) suggested an autoimmune etiology. Thyroid ultrasound confirmed atrophic thyroiditis. Levothyroxine treatment improved the symptoms and laboratory values. Two months after diagnosis, the patient became pregnant. Anemia relapsed during pregnancy, thyrotropin receptor antibodies levels normalized, and postpartum follow-up revealed stable thyroid function without affecting the newborn thyroid function. This case underscores the diagnostic challenges of negative TPOAb and TgAb hypothyroidism, which is often misdiagnosed as Hashimoto's thyroiditis, and highlights the need for functional discrimination in thyrotropin receptor antibodies assays. Thyrotropin receptor antibodies measurements can help in the differential diagnosis of rapidly evolving hypothyroidism in women with negative TPO-Ab and thyrotropin receptor antibodies levels, especially in women of childbearing age. Further research is essential to understand thyrotropin-binding inhibitory immunoglobulin-mediated hypothyroidism and to develop targeted therapies.

Abstract in English:

ABSTRACT Lisdexamfetamine, a prodrug used to treat Attention Deficit/Hyperactivity Disorder in children, adolescents, and adults, is an inactive substance that is converted into its active form (dextroamphetamine) after being metabolized. This conversion primarily occurs in the bloodstream through enzymatic cleavage following active absorption from the gastrointestinal lumen. The active metabolite then stimulates the central nervous system by increasing the levels of dopamine and norepinephrine in the brain. It was discovered in 1996 by New River Pharmaceuticals and approved by the FDA in 2007 for the treatment of Attention Deficit/Hyperactivity Disorder in children. In this article, two cases of secondary Raynaud's phenomenon due to the use of lisdexamfetamine are described. Raynaud's disease is the primary form, occurring in the absence of an underlying cause, and differs from secondary Raynaud's phenomenon, which is associated with various medical conditions and pharmacological agents. In the cases reported in this study, the phenomenon occurred during treatment with lisdexamfetamine, where it is listed as an uncommon adverse effect in the prescribing information. In both patients presented in this report, discontinuation of the medication led to resolution of the phenomenon within a few days. This report highlights the fact that one of the patients reported episodes of dizziness during Raynaud's phenomenon, drawing attention to the potential associated complications.

Abstract in English:

ABSTRACT Lymphatic leakage after pelvic lymphadenectomy is a rare complication. Furthermore, in some cases, drainage is not possible or proves insufficient to resolve this complication. Therefore, more effective and minimally invasive interventional treatments are necessary. Accordingly, this case report presents a case of transafferent nodal embolization in a 50-year-old woman who underwent videolaparoscopic total hysterectomy with pelvic lymphadenectomy. The patient developed high post-surgery vaginal flow due to a lymphatic fistula, which was identified after intranodal lymphangiography and treated successfully via transafferent nodal embolization. This case report shows the importance of considering lymphatic leakage as a possible pelvic surgery complication, particularly when accompanied by local lymphadenectomy. Moreover, the case report reveals that intranodal lymphangiography and transafferent nodal embolization are safe and highly effective methods to detect and treat this complication. This prevents the need for follow-up surgery, which may add morbidity to an otherwise uneventful postoperative period. Level of evidence: Level 5, Case Report.

Abstract in English:

ABSTRACT Platypnea-orthodeoxia syndrome, first described in 1949, is a rare clinical condition characterized by positional dyspnea and oxygen desaturation in the upright position that improves when lying down. Herein, we report the case of an 86-year-old patient who experienced episodes of dyspnea on assuming an upright position, which limited her daily activities. The patient's oxygen saturation was 82% in the standing position and 91% in the supine position. During diagnostic investigation, a patent foramen ovale was identified using transesophageal echocardiography. The patient underwent percutaneous patent foramen ovale closure with an Amplatzer device, which resulted in significant improvement in her symptoms and oxygen saturation. Diagnosis of this condition requires a high index of clinical suspicion and is confirmed when the syndrome's signs and symptoms correlate with the presence of a right-to-left interatrial shunt. It is predominantly diagnosed using echocardiography with agitated saline injection.

Abstract in English:

ABSTRACT Mammoplasty is commonly performed under epidural anesthesia combined with intravenous sedation; however, this carries a risk of dural puncture and post-dural puncture headache. Successful treatment is often achieved with opioids, non-steroidal anti-inflammatory drugs, and caffeine. When conservative treatment fails, an epidural blood patch should be performed; this procedure has a high resolution rate. We report the case of a patient who developed a post-dural puncture headache 25 days after elective breast implant replacement performed under thoracic epidural anesthesia combined with intravenous sedation. The post-dural puncture headache was refractory to conservative treatment and the first epidural blood patch was unsuccessful. This case represents an exceptionally rare presentation of post-dural puncture headache, marked by a delayed onset of nearly four weeks and requiring a second epidural blood patch for symptom resolution.

Abstract in English:

ABSTRACT Groove pancreatitis is a rare form of chronic pancreatitis that affects the anatomical area between the head of the pancreas, medial wall of the second part of the duodenum, and common bile duct, known as the groove area. We present the case of a 40-year-old female patient with recurrent acute abdominal pain, vomiting, inappetence, and weight loss over several months. Diagnostic imaging revealed obliteration of fat in the pancreaticoduodenal groove and densification of the adjacent adipose planes, along with an infiltrative and stenosing lesion in the duodenum. Despite negative biopsy results, the patient's symptoms persisted, leading to a multidisciplinary decision regarding surgical intervention. Initially, a less-invasive robotic gastroenteric anastomosis was performed; however, this did not yield the desired outcome. Consequently, after further episodes of pancreatic inflammation, a more extensive pancreaticoduodenectomy (Whipple procedure) was performed. The patient showed significant clinical improvement postoperatively, with no recurrence of symptoms. Groove pancreatitis poses a diagnostic challenge owing to its nonspecific clinical presentation and imaging findings. Although management typically involves dietary changes, medication, and endoscopic interventions, surgical intervention may be necessary in cases of recurrent symptoms or complications. This case highlights the importance of a multidisciplinary approach in managing groove pancreatitis and underscores the potential efficacy of surgical intervention in achieving symptomatic relief and improving quality of life, even in atypical patient demographics.

Abstract in English:

ABSTRACT Vulvar cancer, a rare gynecological malignancy, accounts for 3-5% of cases and is most commonly squamous cell carcinoma. Prognosis is poorer in cancers unrelated to human papillomavirus (HPV), often associated with chronic inflammation. We report the case of a 42-year-old woman from São Paulo, Brazil, who presented with a vulvar lesion initially misdiagnosed as an ingrown hair. Despite treatment, the lesion progressed, and subsequent evaluation revealed invasive squamous cell carcinoma. Biopsy confirmed HPV-independent disease, with immunohistochemistry demonstrating aberrant p53 expression. Molecular analysis identified differentiated vulvar intraepithelial neoplasia, underscoring the distinct molecular pathways of HPV-related and HPV-independent carcinogenesis. This case emphasizes the importance of early diagnosis, comprehensive histopathological assessment, and further research to improve management and outcomes in HPV-independent vulvar cancer.

Abstract in English:

ABSTRACT Lower back pain and sciatica account for approximately 40% of work-related absences, with management options ranging from conservative measures, such as rest and analgesia, to surgical intervention. Lumbar epidural steroid injections and facet joint blocks are frequently used for both diagnostic and therapeutic purposes. While most complications are minor (2.4%-9.6%), severe events, including infection, hematoma formation, and spinal cord infarction, have been reported. This case presents a perineural hematoma manifesting as acute radiculopathy, necessitating urgent surgical decompression. The patient was a 55-year-old woman with a 7-month history of low back pain radiating to her right leg, unresponsive to conservative treatments, who subsequently underwent facet and nerve root injections. Magnetic resonance imaging demonstrated lumbar degeneration with Modic changes and multilevel disc bulging. The procedure, performed under fluoroscopic guidance with contrast and therapeutic agents, was initially uneventful. However, on the third day post-injection, she developed acute left leg weakness and sensory impairment. Repeat magnetic resonance imaging showed an abnormal signal in the left L3-L4 foramen compressing the L3 nerve root, raising suspicion for a perineural hematoma. Urgent surgical decompression was performed, and pathological examination confirmed organizing hemorrhage. The patient's neurological symptoms improved rapidly, with complete recovery achieved within a month. The literature indicates that hematomas may arise from increased epidural pressure or direct needle injury, even in the absence of signs of bleeding. Practitioners should remain vigilant for post-injection hematomas, as delayed recognition can result in permanent neurological deficits. Magnetic resonance imaging is essential for timely diagnosis, and urgent decompression may optimize outcomes, given that earlier intervention is associated with better recovery.

Abstract in English:

ABSTRACT Snakebites from the genus Bothrops account for up to 90% of venomous snakebites in Brazil. Among these species, Bothrops taeniatus is considered rare in Brazil, with only one reported case in the literature. Its venom has a strong hemorrhagic effect but lacks procoagulant activity, which can lead to significant variations in the neutralizing efficacy of anti-Bothrops serum. We describe the first case of severe envenomation by B. taeniatus with rapid recovery following the administration of anti-Bothrops serum in Brazil, and discuss the characteristics of B. taeniatus envenomation based on a literature review.

Abstract in English:

ABSTRACT This report presents a case of a 59-year-old male diagnosed with metastatic esophagogastric junction adenocarcinoma, who presented with mild dysphagia and vertigo. Brain magnetic resonance imaging initially showed no abnormalities. Upper gastrointestinal endoscopy revealed a vegetative lesion in the distal esophagus, and concurrent colonoscopy identified a laterally-spreading tumor in the transverse colon. Immunohistochemistry confirmed a poorly differentiated adenocarcinoma, suggesting an upper gastrointestinal origin. Further investigation of the worsening neurological symptoms led to the identification of leptomeningeal carcinomatosis via cerebrospinal fluid analysis. Somatic genetic testing detected TP53 mutations and CDK6 amplification; however, no germline mutations were identified. The patient received first-line treatment with 5-fluorouracil, leucovorin, oxaliplatin, and nivolumab, followed by whole-brain radiotherapy due to rapid progression of the leptomeningeal disease. Despite aggressive treatment, the patient experienced multiple complications, including pulmonary embolism and seizures, and died from disease progression after six cycles of therapy. This case highlights the diagnostic challenges and poor prognosis of metastatic esophagogastric junction adenocarcinomas with de novo meningeal and colonic involvement and underscores the importance of early diagnosis and comprehensive evaluation of atypical presentations to optimize patient management.

Abstract in English:

ABSTRACT Intestinal worm infections, referred to as helminthiases, represent a significant global health challenge, particularly in low- and middle-income countries. These infections affect millions of people and contribute to malnutrition, anemia, and impaired cognitive development, particularly in children. Nitazoxanide, first described in 1975, was initially developed as a veterinary anthelmintic. It has shown efficacy against various pathogens including Giardia lamblia, Entamoeba histolytica, and Cryptosporidium parvum. Recently, its use has expanded due to its observed in vitro activity against viruses, including coronaviruses. Nitazoxanide, a derivative of salicylamide, combines a nitrothiazole moiety with a salicylic acid moiety. Anaphylaxis, a severe immediate hypersensitivity reaction, may be induced by medications, with nonsteroidal anti-inflammatory drugs being among the most common causes. However, neither immediate hypersensitivity reactio, including anaphylaxis, to nitazoxanide nor cross-reactivity with nonsteroidal anti-inflammatory drugs has been previously reported. This study reports four cases of immediate hypersensitivity reactio to nitazoxanide in patients with non-selective immediate hypersensitivity reactio to nonsteroidal anti-inflammatory drugs. These findings highlight the need for vigilance in monitoring medication reactions and suggest the inclusion of nitazoxanide in the list of medications to be avoided in these patients.

Abstract in English:

ABSTRACT Hypersensitivity pneumonitis is an inflammatory lung disease caused by antigen inhalation after sensitization. Here, we report a rare case of the simultaneous diagnosis of hypersensitivity pneumonitis and epithelioid mesothelioma, a subtype of malignant mesothelioma. A 71-year-old man presented with an occasional dry cough and exertional dyspnea that had persisted for about 1 year. He reported walking daily in a park with a considerable number of birds during same period. Functional evaluation revealed a mild restrictive ventilatory disorder. High-resolution computed tomography showed nonspecific peripheral interstitial lung involvement along with signs of bronchopathy and diffuse bronchiolopath without honeycombing or bronchiectasis. Owing to the patient's clinical history and the presence of a restrictive ventilatory disorder, a biopsy was performed for diagnostic clarification. Pathological examination revealed hypersensitive pneumonitis associated with epithelioid mesothelioma. Surgical resection of the mesothelioma and avoidance of occupational exposure resulted in complete regression of symptoms and improvement in radiological findings. A report on this rare concomitant diagnosis of the hypersensitivity pneumonitis and epithelioid mesothelioma is essential for advancements in medicine.

Abstract in English:

ABSTRACT Stress fractures of the sacrum are extremely rare differential diagnoses for persistent low back pain in pregnant and postpartum women. The common occurrence of low back pain due to mechanical overload on the spine, coupled with challenges in obtaining imaging studies during this phase of a woman's life, often delays and compromises the accurate diagnosis of sacral fatigue fractures. We report the rare case of a postpartum patient who underwent surgery for lumbar disc herniation one year and one month earlier and was diagnosed with an atraumatic sacral fracture.

Abstract in English:

ABSTRACT T-cell prolymphocytic leukemia is a rare and aggressive mature T-cell malignancy that usually presents with marked lymphocytosis, hepatosplenomegaly, lymphadenopathy, and B symptoms. However, a minority of patients present with an indolent, asymptomatic form. Case Report: A 44-year-old man was diagnosed with asymptomatic T-cell prolymphocytic leukemia after routine blood tests revealed persistent lymphocytosis. Immunophenotyping revealed a mature CD4-/CD8+ T-cell population. Cytogenetic analysis showed 14q11.2 abnormalities with TCRAD rearrangement by fluorescent in situ hybridization. A monoclonal T-cell population was confirmed by flow cytometry and polymerase chain reaction, and a STAT5B mutation was identified by next-generation sequencing. The patient had no cytopenia or organ involvement and a watch-and-wait strategy was adopted. The pathogenesis of T-cell prolymphocytic leukemia involves recurrent genetic alterations, including TCL1A rearrangements and ATM mutations, which promote genomic instability. Despite their aggressive nature, up to 30% of cases initially follow an indolent course, allowing for observation rather than immediate treatment. Standard therapies include alemtuzumab-based regimens and hematopoietic stem cell transplantation, although relapse rates remain high. Conclusion: This case underscores the need to recognize indolent presentations of T-cell prolymphocytic leukemia that may be managed conservatively. Further research is required to identify prognostic markers and optimize therapeutic strategies.

Abstract in English:

ABSTRACT The 48,XXYY syndrome is a rare sex chromosome aneuploidy associated with diverse physical, developmental, and endocrine abnormalities. This case report highlights a 15-year-old male with 48,XXYY syndrome presenting with hypopituitarism and a Rathke's cleft cyst, offering insights into the interplay between genetic syndromes and pituitary dysfunction. The patient exhibited hyperprolactinemia, central hypothyroidism, central hypoadrenalism, and elevated gonadotropin levels. Brain magnetic resonance imaging revealed a cystic lesion within the sella turcica, consistent with a Rathke's cleft cyst. The patient also had autism and severe essential tremor. Physical examination revealed a reduced testicular volume without gynecomastia, and genetic analysis confirmed a 48,XXYY karyotype. Hormone replacement therapy with prednisone and levothyroxine was initiated, resulting in adequate hormonal replacement. Follow-up magnetic resonance imaging demonstrated stability of the pituitary cyst, with no evidence of progression. This case highlights the importance of hormonal evaluation in patients with rare sex chromosome aneuploidies. Routine pituitary hormone evaluation and imaging should be integral to the care of individuals with 48,XXYY syndrome. These findings highlight the value of a multidisciplinary approach that integrates endocrinology, genetics, and neurology to address the complex needs of these patients. The association between 48,XXYY syndrome and Rathke's cleft cyst raises intriguing questions about the potential links between sex chromosome aneuploidies and pituitary abnormalities. This report emphasizes the need for comprehensive endocrine and structural assessments to optimize patient outcomes by contributing to the limited literature on 48,XXYY syndrome.